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NURS 3320 MED SURG EXAM 3 {2020}– Northeastern University | NURS3320 MED SURG EXAM 3

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NURS 3320 MED SURG EXAM 3 – Northeastern University Medical Surgery Exam 3 Neurological Disorders Management of Patient’s with Neurological Disorders Level of Consciousness (LOC) • Ale... rt and oriented o Oriented to person, place, time o Are they able to follow commands o Do they need consistent stimuli • There is a continuum o Where are they o Confused, drowsy, coma • May begin with subtle changes o May begin with restlessness or anxiety • Mental status, cranial nerves, cerebral function, motor function, sensory function o Clinical Manifestation:  Pupillary response  Eye open response  Verbal response o Change in LOC is risk for alteration in every body system  Evaluate mental status  Cranial nerve function  Motor function  Cerebral function balance  Sensory  sharp vs dull • Interventions o Mouth care o IV o I and O o Skin integrity o ROM o Maintain body temp (do not take oral temp) o Promote bowel function o Care for family o Prevent urinary retention • Medical and Nursing Management o CT, MRI, EKG o As LOC changes make sure to maintain:  Airway  Circulatory status  Perfusion of the body/brain  Admin IV Fluid • NANDA o Ineffective airway clearance o Risk of injury o Deficient fluid volume o Nutrition imbalance o Impaired skin integrity Glascow Coma Scale • Most common scoring system used to describe the level of consciousness in a person following a traumatic brain injury. • Looks at o Eye opening o Verbal response o Motor response • Interventions o Negative fluid balance o I and O o Serum urine osmolality o Maintain skin integrity o Oral hygiene o Prevent infection o Monitor for change in ICP and LOC Intracranial Pressure (ICP) • Maintaining ICP o ICP= Skull+ Brain+ fluid o Stats of equilibrium of the content • Monroe-Kellie Hypothesis o Limited space in the skill o An expansion of one causes a problem to occur with the other o Example: if the brain swells the fluid has to go somewhere else o Change in content leads to ICP rising or other content is displaced • Change in blood, flow, edema, pressure o Increase in ICP , decrease in cerebral profusion and increase in further swelling  Causes a herniation o Decrease cerebral blood flood, edema, and response o Signs:  Slow pulses  Respiratory irregularity  Change in blood pressure  Change in LOC  Change in VS o Worse it gets the worse the symptoms get  Patient can become comatose  Decortication= abnormal flexion or arms and extension of the legs  Degarabation= extreme extension of all extremities • May be flaccid • Pupils may be dilated or fixed • Look at respitations • Change in LOC • Assessment: o LOC o CS o Respiratory o Prevent complication • Maintain o Airway o I and O o Fluid volume o Tissue perfusion o Negative fluid balance o Prevent infection • Management o Determine the cause:  Trauma, stroke  CT, MRI, doppler o Decrease edema o Maintain cerebral profusion o Decrease volume (keep fluid down)  Osmotic diuretic  Restrict fluids  Drain fluid  Reduce metabolic demand o Complications  Brain stem herniation  Diabetes inspidus  SINDH Seizures • Electrical disturbance in the brain’s nerve cells • Causes o Fever o Cerebrovascular disease o Head injury o Tumor o Metabolic conditions o Infection o Epilepsy o Sodium imbalance • Seizures can differ from absence to status epilepticus o Episodic: 1 seizure at a time o Statius epilepticus: multiple seizure o Absence seizure: no movement o Mild contraction: unusual sight, sound, taste, no change in LOC o Tonic-clonic : involves both side of the brain  More severe o Abnormal motor or autonomic function  Electrical disturbance  LOC  Change in movement  Change in behavior • Management o Keep the patient safe  Ease them onto the flood if they are standing  Protect head remove pillows o Document  What happened, what area of the body o Provide privacy o Stay with the patient  Call for help o Medical management o NEVR RESTRAIN PATIENT o DO NOT ATTEMPT TO OPEN MOUTH DURING SEIZURE o Keep patient on one side if you can o May need to insert oral airway to keep them from biting their tongue o Ativan to relax them Headaches • Cephalagia • Types of headaches o Primary: headache with no specific organic cause o Secondary: results from another disease like tumor or brain aneurysm o Different types  Tension: tension of muscles causes the headache  Cluster: unilateral pain or severe episodes of pain • Crescendo- decrescendo pattern  Head or neck trauma  Vascular cranial dyfunction  Infection  Homeostasis  Other headaches can be caused by: coughing, emptions, sexual activity • Migraines o Specific diagnosis o Phase 1:  Prodronal phase  Right before the migraine (hours or a day)  Depression, irritability, change in activity, bowel habit change o Phase 2  Aura  Something that happens that the patient knows they are about to have a migraine o Phase 3  The actual headache part  Throbbing headache  Incapacitating  No lights or sound  Nausea and vomiting o Phase 4  Recovery  Pain resides  Muscle contraction  May have a little headache  Patient may be very tired • Assessment o How did it manifest o What were you doing before o Co-morbidities o Associated symptoms o Stressors? o Description of headache:  Where is it  Pain assessment  Quality  How many occur during the day • Nursing Management o Medical management  Opioids  Non-opioids o Head and other comfort measure o Keep quiet o Elevate bed o Keep lighting down Care and Management of Patient’s with Cerebrovascular Disorders Stoke Patho • Ischemic stoke o Brain attack CVA o Blockage in blood vessel supply to the brain • Small penetrating artery thrombosis o Blockage in 1 or more of the vessels o Causes death to surrounding tissue • Larger artery thrombosis o Astherolsclerosis plaque in larger vessels of the brain • Cardiogenic thrombotic stroke o Cardiovascular dysthymia afib o Heart not pumping properly and pools into heart making plaque that travels to the brain • Criptogenic o No known cause • Others o Drugs o Mirganes o Spontaneous disease of the carotid artery • Obstruction of the blood vessels o Series of events: ischemic cascade  Cerebral blood flow diminishes  Neurons cant maintain aerobic respiration • Changes to anaerobic respiration • Lactic acid is produce • Changes PH • ATP can’t be made • Electron pump fails • Cells die  Penumbral region: where cells die • Focus intervention here because you want to salvage the brain  Calcium glutamate released causes more damage • Blockage cells die Ischemic Stoke • Clinical Manifestations o Dependent on where the stroke is o Dependent on time of infraction o Numbness, weakness of face arm and leg • Neurological Deficits o Hemiphorisis: weakness of face arm and leg on one side o Hemoipolygia: paralysis on face, arm, or leg on opposite side of stroke o Confusion and change in mental status • Visual Field Deficits o Double vision o Loss of peripheral vision o Loss of half of the visual field • Motor Deficits • Sensory Deficits • Verbal and cognitive deficits o Trouble speaking or understanding speech o Expressive aphasia: unable to produce language o Receptive aphasia: unable to comprehend language o Mixed aphasia: unable to produce or comprehend language - -- - - - - - - - - - - - - - - - - - - - - - - - - - activities that involve raising the arms about shoulder level: True • T/F: With an open fracture, the wound should be covered with a sterile dressing and no attempt should be made to reduce the fracture: True • T/F: The patient with a clavicle fracture should be encourage to elevate the affected arm abov shoulder level after 72 hours to increase range of motion: False • T/F: Closed reduction is an acute care management interventions for a dislocated shoulder: True • The treatment of contusions, strains, and sprains consists of intermittent application of moist of dry cold packs for up to 72 hours after injury • A crumbling sensation (caused by the rubbing of bone fragments against each other), called crepitus can be felt when gently palpating an extremity fracture • The chest x-ray of a patient with fat embolism syndrome may show nothing of significance of there may be evidence of the classic snowstorm infiltrate • Although pulmonary complications, fat emboli, thromboembolic complications, and infection are all possible complications of unstable pelvic fracture, the high mortality rate is primarily related to hemorrhage • Phantom limb pain is described as a sensation that an amputated extremity is still present but is cramped or in an abnormal position Module 11: Surgery • You admit a patient to the PACU who has undergone a surgical procedure that required the use of general anesthesia. What is the patient most at risk for following general anesthesia: Atelectasis • As an intraoperative nurse, you know that the patient's emotional state can influence the outcome of his or her surgical procedure. How would you best reinforce the patient's ability to influence their outcome: Incorporate cultural, ethnic, and religious considerations as appropriate • You are caring for a preoperative patient. You have given the patient a preoperative narcotic and the patient is now requesting to void. What action should you take: Offer the patient a bedpan. • Which of the following events subjects the surgical patient to possible injury in the intraoperative phase of the surgical experience: ability to communicate, reflexes, loss of pain sense • A nurse is caring for a patient following surgery under a spinal anesthetic. What interventions can the nurse implement to prevent a spinal headache: keep the patient lying flat • The nurse's aide notifies you that your patient has decreased oxygen saturation levels. You assess the patient and find that he is tachypnic, has crackles on auscultation, and his sputum is frothy and pink. What do you suspect is wrong with this patient: flash pulmonary edema • Your patient has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. What is your first response: Place saline-soaked sterile dressings on the wound • You are the PACU nurse caring for a patient who is ready to go the floor after her surgery. What would you be responsible for reporting to the nurse on the floor: the patient’s preoperative level of consciousness, the presence of family and/or significant others, identification of the patient by name • You are doing a preoperative assessment on a patient going to surgery. The patient informs you that he ingests 5 to 10 ounces of alcohol each day and has for the last 15 years. What postoperative difficulties can the nurse anticipate for this patient: delirium tremens within 72 hours after his last alcohol drink • Your patient is in the recovery room following chest surgery. The patient complains of severe nausea. What would you do next: turn the patient completely to one side • You are obtaining the patient's signature on the surgical consent form. What are the criteria for a valid informed consent: consent must be given freely, consent must be obtained by a physician, signature must be witnessed by a professional staff member • You note a colleague making an inappropriate remark about the patient's weight. The patient is unconscious at the time. What should you do: discourage the comments • T/F: the primary objective in the immediate postoperative period is to maintain ventilation and prevent hypoxemia and hypercapnia: True • T/F: cardiogenic shock is the most common type of shock that occurs as a postoperative complication: False • T/F: Assessment of respiratory status in the hospitalized postoperative patient is imperative because pulmonary complications are the most frequent problems encountered by the surgical patient: True • T/F: The valsalva maneuver can prevent wound healing by producing tension on surgical wounds: True • T/F: the first symptoms of deep vein thrombosis may be a pain or cramp in the calf: True • In phase 3 of postanesthesia care the patient would be prepared for discharge • Hypopharyngeal obstruction occurs when the lower jaw and tongue fall backwards and air passages become obstructed • An uncommon yet serious complication of surgery that can result in hypovolemic shock and death is hemorrhage • Many hospitals use a scoring system called Aldrete Score, which is used to determine the patient’s general condition and readiness for transfer from the PACU • A major nursing diagnosis in the postoperative period may include decreased cardiac output related to shock or hemorrhage Module 12: Immune Dysfunction • The nurse is assessing a 28-year-old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations takes immediate priority Tachypnea and restlessness • The nurse is developing a teaching plan for a patient with rheumatic disease who is being prescribed salicylate therapy to monitor herself for what Tinnitus • The nurse knows that as the symptoms of a disease change, modifications need to be made in the treatment plan. The nurse would teach the patient with rheumatic disease that it is acceptable to perform passive range of motion during which phase of the inflammatory process: Acute exacerbation, severe pain • Since the HIV/AIDS epidemic began health professionals have learned much about the virus that causes the disease and the disease process itself. The human immunodeficiency virus (HIV) belongs to a group of viruses known as retroviruses. What patient is at the greatest risk of contracting HIV: Injecting drug user • A patient has come into the free clinic asking to be tested for HIV infection. The patient asks the nurse how the test works. The nurse responds that if the testing shows antibodies to the AIDS virus are present in the blood, this indicates what: The patient has been infected with HIV • A patient with rheumatoid arthritis calls the nurse and reports having mild side effects from his medication. The patient also tells the nurse his disease is worse and he is losing some of his ability to function. The nurse schedules an appointment for the patient to see the physician that afternoon. What order might the nurse expect to receive from the physician for this patient: Decrease the dosage of the medication. • The nursing instructor is going over laboratory results for HIV/AIDS patients. The instructor tells the students that upon interpretation of a patient's laboratory results, the nurse should recognize that a patient with HIV is considered to have AIDS when the CD4+ T-lymphocyte cell count drops below what: 200 cells/mm3 of blood • A patient in the early stage of rheumatoid arthritis has been admitted to your unit. What medication classification would the nurse expect to be ordered for this patient: NSAID • You are caring for a patient hospitalized with AIDS. The family comes to visit and a family member asks you about safety when visiting a patient with AIDS. What is the best response for addressing the family member's fears: “AIDS is commonly transmitted by contact with blood and body fluids.” • The clinic nurse is caring for a patient newly diagnosed with fibromyalgia. When developing a care plan for this patient, what would be a priority nursing diagnosis for this patient: fatigue • T/F: Primary immunodeficiency disease results from external factors such as infection: False • T/F: People with primary immunodeficencies are predisposed to developing cancer, especially non-hodgkins lymphomas: true • T/F: Burton’s disease, a b-cell deficiency is characterized by the disappearance of all antibodies from the patient’s plasmas: True • T/F: Common variable immunodeficiency (CVID), the most common primarily immunodeficiency seen in infants is more common in males than females: false • T/F: Nursing management for patients with immunodefiences includes educating the patient to recognize the signs and symptoms of infection: true • Immunodeficiency disorders may be caused by a defect in, or a deficiency of, phagocytic cells, b lymphocytes, t- lymphocytes, or the complement system • Pernicious anemia, an immunodefiency disorder affecting b lymphocytes can be treated with vitamin b12 • The most frequent presenting sign in infants (usually within the first 24 hours of life) with DiGeorge syndrome is hypocalcemia which is resistant to standard therapy • The two most common autoimmune manifestation that often cause considerable morbidity and mortality for patients with wiskott-aldrich syndrome (WAS) are vasculities and autoimmune hemolytic anemia • Nursing management of a patient who requires immunosuppression must include use of standard precautions when providing care to prevent infection • T/F: Most new HIV infection each year occur in gay, bisexual, and other men who have sex with men: True • T/F: approximately 60% of people living with HIV are over the age of 50: false • T/F: During the first stage of HIV infection, the patient may be asymptomatic: true • T/F: Kaposi’s sarcoma is the most common HIV related malignancy: true • T/F: Combination chemotherapy and radiation therapy regimens have produced excellent and long-lasting remission of AID related lymphomas: False • Mother to child transmission of HIV 1 may occur in utero, during delivery, or through breastfeeing • Postexposure prophylaxis for health care workers exposed to HIV involves starting prophylaxis medications within 2 hours after exposure and continuing the HIV medications for 4 weeks after exposure • Stage 1 or primary stage of HIV infection is characterized by high levels of viral replications and widespread dissemination of HIV throughout the body • Candidiasis is a fungal infection that occurs in almost all patients with AIDs and immune depression • Peripheral neuropathy is the most common neurologic symptoms at any stage of HIV infection [Show More]

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NURS 3320 MED SURG EXAM 1, 2 & 3 {2020} – Northeastern University

NURS 3320 MED SURG EXAM 1 {2020} – Northeastern University NURS 3320 MED SURG EXAM 2 {2020} – Northeastern University NURS 3320 MED SURG EXAM 3 {2020} – Northeastern University

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