PN 161 Practical Nursing III Final Exam Study Guide.

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Study Guide for PN 161 Practical Nursing III Final Exam Module 1 and 2 1. Identify how to properly assess a client using the Glasgow coma scale and important nursing interventions related to sc... oring. a. The Glasgow coma scale measures eye opening, verbal response, and motor response i. Monitor for improvements or worsening signs b. See level of consciousness! c. 3 is the lowest score d. Highest score 15 e. A score of 7 or less is considered a state of coma 2. Understand important considerations for neurological assessments. a. Health history i. Headaches ii. Clumsiness iii. Loss or change in function of extremity iv. Seizure activity v. Numbness or tingling vi. Change in vision vii. Pain viii. Extreme fatigue ix. Personality changes or mood swings 3. Review the physiology of CNS, PNS, and sympathetic/parasympathetic nervous systems. a. CNS i. Brain 1. Controls, initiates, and integrates body functions ii. Spinal cord 1. Carries sensory impulses a. Cerebrospinal fluid i. Absorbs shock b. PNS i. Somatic nervous system 1. Conscious activities ii. Autonomic nervous system 1. Unconsciousness activity iii. Spinal nerves 1. Reflex activity c. Sympathetic i. Neurological 1. Pupils dilated 2. Heightened awareness 3. Fight or flight d. Parasympathetic i. Neurological 1. Pupils normal size 2. Rest and digest 4. Identify important observations to include when assessing a pt.’s. mental status. a. Appearance b. Behavior c. Posture d. Mood e. Gestures f. Movements and facial expressions 5. Safety factors in Parkinson’s patients. a. Ambulation with assistance b. Provide an elevated toilet seat 6. S/S of encephalitis, meningitis and review nursing actions when caring for patients with them. a. Encephalitis i. Inflammation of brain ii. Fever, headache, nuchal rigidity, photophobia, irritability, lethargy, nausea/vomiting b. Meningitis i. Inflammation of meninges ii. Fever, headache, nuchal rigidity, photophobia, irritability, lethargy, and nausea/vomiting c. Nursing care i. Monitor for changes in neurological status ii. Quiet environment decreases external stimulation iii. Observe for seizure activity and protect from injury iv. Comfort measures offered 7. Post-op care of patient following back surgery. a. Monitor neurological status and vital signs b. Encourage client to cough, deep breathe, use incentive spirometer hourly, and move legs as allowed c. Provide adequate fluids to prevent renal stasis and constipation 8. List the S/S of herniated disks. a. Pain b. Motor changes c. Sensory changes d. Alterations in reflexes 9. S/S and exacerbations of them in MS patients. a. S/S of MS i. Vary according to the areas of demyelination ii. Vary from hour to hour or day to day iii. May be sensory, motor, or other disturbances 1. Visual disturbances 2. Numbness 3. Paresthesia 4. Pain 5. Decreased sense of temperature 6. Decreased muscle strength 7. Spasticity 8. Paralysis 9. Bowel and bladder incontinence or retention [Show More]

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