NR 603 WEEK 1 QUIZ – QUESTIONS AND ANSWERS – CORRECT RATED A+

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NR 603 WEEK 1 QUIZ – QUESTIONS AND ANSWERS – CORRECT RATED A+ Which of the following are potential causes of delirium in the elderly? Mark all that apply. Dehydration Medication Effects Sepsi... s Metabolic imbalance Question 2 Personality changes in patients with Traumatic Brain Injury include all of the following except: Hypervigilance Impaired Social Judgment Apathy Impulsivity Question 3 Common presenting symptoms of dementia include all of the following except: Depression Irritability Inability to find the right words Abstract thinking increases Question 4 Which type of medication may be particularly dangerous when treating aggression in patients with traumatic brain injury (TBI) because it could cause paradoxical agitation? Benzodiazepines Clonidine Haloperidol Propranolol Question 5 Chris is a 28-year-old marine who just returned from active duty from Iraq. He has been complaining of dizziness, extreme headaches, and memory problems related to traumatic brain injury. His neurological injuries are most likely the effect of: Changes related to altitude in climate. Rotational acceleration/deceleration, resulting in focal injury. Diffuse axonal damage as the result of a blast-induced injury. Direct blunt trauma, resulting in damage to underlying tissues. Question 6 A pleasant 73-year-old male presents to the clinic with his wife. His wife states that she has noted increasing problems with his memory including forgetting to get some items on his grocery list and misplacing his car keys. You administer the MMSE in the office and he scores 24/30 which is consistent with Mild Dementia per the scoring guidelines. Your best response to his wife is: The MMSE score alone is a strong indicator of Dementia and we can proceed with medication based on these results. The MMSE score along with the memory issues are more concerning for head injury and so we will pursue a head CT to rule out TBI. The MMSE score alone is concerning for Dementia but the memory issues can be a part of normal brain function so we need to rule out organic causes before concluding a diagnosis of Dementia. The MMSE score along with the memory issues you identified are very strong indicators of Dementia so we will begin first line treatment with Donepezil (Aricept) today. Question 7 Collaborating with specialists is an important part of primary care involving patients with neurologic injuries. It is important as an APN to know when to refer to a specialist and what the goal of that referral is: further information, diagnostic testing or treatment recommendations? Which of the following are accurate goals of referral of a patient for Neuropsychological Testing? Choose all that apply: Marital Counseling Assist in identifying neurobehavioral or developmental disorders that may influence cognitive and behavioral functions (e.g., dyslexia, attention-deficit/hyperactivity disorder [ADHD], autism spectrum disorders, mental retardation) Monitor the results of Court ordered Drug testing Monitor changes in cognition over time (document recovery or progression of symptoms) Establish a baseline level of neuropsychological functioning Assist in differential diagnosis and determination of the severity of a condition Question 8 Key early warning signs for Alzheimer’s disease include all of the following except: Problem with language Loss of initiative Memory loss Increased fatigue Question 9 Benzodiazepines are appropriate for which of the following disorders? (Choose all that apply) Insomnia Mood Disorders Acute alcohol withdrawal Delirium Question 10 Match the type of Injury with the neurologic damage. Blow to the head with an object Focal and diffuse damage Damage to underlying tissue or vessels Punched in the face or head Contusions/bruising/bleeding Being shot in the face or head Focal and diffuse damage Disintegration of brain tissue Falling and hitting your head Diffuse damage Focal and diffuse damage Near Drowning Focal and diffuse damage Diffuse damage The WEEK 1 QUIZ focuses on the assessment, diagnosis, and treatment Delirium is characterized by a . disturbance in attention, consciousness, and cognition. the HALLMARKof delirium is a clouding of consciousness, with an inability to focus, sustain, or shift attention, as well as a change in cognition, including impairment in short-term memory, disorientation, and perceptual disturbances. Diagnostic Criteria for Delirium A. A disturbance in attention and awareness B. The disturbance develops over a SHORT period of time (usually hours to a few days), C. An additional disturbance in cognition (e.g., memory deficit, disorientation, language, visuospatial ability, or perception). Diagnostics for delirium Chest x-ray study, Other Diagnostics, ECG, Head CT or MRI*, Lumbar puncture* CBC and differential, ESR, Platelet count, Serum electrolytes, Serum glucose, Calcium, Magnesium, Phosphorus, BUN, Creatinine, LFTs, Vitamin B12, Folate, Thiamine, Ammonia, Thyroid function tests Which tool is now the most widely used tool for evaluation of the presence of delirium: The Confusion Assessment Method Which medication class has long been implicated as a risk factor for delirium :Anticholinergic medications Treatment of delirium is both- definitive and palliative Definitive care of those with delirium is aimed at identification and treatment of the precipitating causes palliative care of those with delirium is directed toward- the management of symptoms, such as agitation, restlessness, and hallucinations. These medications may be useful in controlling agitation and psychosis, although there is no compelling evidence that demonstrates improvement in the prognosis of delirium with their use Antipsychotic medications such as haloperidol and droperidol These newer medications may be used in small doses for behavior management in the short term when patient or staff safety is compromised. Newer antipsychotics such as risperidone, quetiapine, and olanzapine These medications are useful in the treatment of alcohol and sedative withdrawal. Benzodiazepines. The goals of treatment for the patient with delirium are to, promote recovery, to prevent additional complications, to maintain the patient's safety, maximize function. Meniere’s Disease -What is Meniere's disease? Meniere disease is a chronic condition of the inner ear characterized by recurrent vertigo and hearing loss. -What are the four symptoms characterized by Meniere's disease?1.dizziness described as spinning vertigo, 2. low- frequency sensorineural hearing loss, 3. tinnitus, 4. a feeling of fullness in the affected ear. Pathophysiology of Meniere's Disease -Meniere disease involves excess fluid and pressure in the labyrinth of the inner ear that episodically distends the structures of the labyrinth and damages the vestibular and cochlear hair cells -Causes of Meniere's Disease--caused by viral infections or immune system-mediated mechanisms -Clinical Presentation of Meniere's Disease- Early in the disease process-patients have intermittent attacks of vertigo that last from minutes to hours, often associated with nausea and vomiting.These episodes are commonly accompanied by pressure in the ear, low-pitched tinnitus fluctuating in intensity, and unilateral hearing loss -Diagnosis of Meniere disease is based on--clinical criteria and/or response to treatment; however, it is important to differentiate Meniere disease from other causes of vertigo and hearing loss -Physical Examination of Meniere's disease should include -A thorough head and neck examination to exclude acute otitis media or another infectious process, a comprehensive neurologic examination a, On physical examination, sound will lateralize to the unaffected ear in the Weber test;in the Rinne test, air conduction will be greater than bone conduction.Spontaneous nystagmus occurs during attacks and may not be present between attacks. -Diagnostic criteria for Meniere's disease include---two episodes of spontaneous vertigo lasting at least 20 minutes each, audiometrically documented hearing loss, tinnitus or aural fullness, and the exclusion of other causes -Diagnostic testing for Meniere's disease include: an audiogram, and MRI to rule out central nervous system (CNS) lesions -Laboratory testing for Meniere's disease include: thyroid-stimulating hormone (TSH), rapid plasma reagin (RPR) testing for syphilis, serum glucose, and Lyme serologies -Differential Diagnoses for Meniere's disease include Benign Paroxysmal positional vertigo, Vestibular neuritis, Vertebrobasilar insufficiency, Acoustic neuroma, Migraine headache -If Meniere's disease is suspected a referral to otolaryngologist should be made -The goals of care for Meneires Disease includes: managing vertigo, Arresting the disease process For symptomatic relief of Meneires Disease what medications should be used? meclizine and antiemetics such as promethazine (Phenergan) may be beneficial for some patients -Patient and family education regarding Menieres Disease includes: Patient safety during acute episodes of vertigo and the sedative side effects of prescribed medications Traumatic Brain Injury is defined as an alteration in brain function, or other evidence of brain pathology CAUSED BY AN EXTERNAL SOURCE -The Glascow Coma Scale is defined as: the measurement tool most frequently used to measure the level of consciousness immediately following an injury -The three categories that makes up the GCS eye opening, motor response, verbal response -Which GCS score indicates severe Traumatic Brain Injury?8 or less -Which GCS score places an individual in the moderate severity Traumatic Brain Injury? 9-12 -Which GCS score places an individual in the mild severity Traumatic Brain Injury?13-15 -Major leading cause of Traumatic Brain Injury--Falls in both adults and children -Two main phases of primary injury that can result in cognitive dysfunction aredirect impact & rotational acceleration The two main phases of injury, direct impact and rotational acceleration, give rise to systemic complications and cellular injury mechanisms that result in... cell death, axonal injury, impaired synaptic plasticity 4 categories of s/s of concussion physical, cognitive, emotional, sleep -What is the most common symptom of a concussion---headache -What is the definition of post concussion syndrome the persistence of post-concussive symptoms beyond the expected timeframe. symptoms occurring 7-10 days after a mild traumatic brain injury that CAN LAST FOR WEEKS TO MONTHS AND UP TO A YEAR -Persons experiencing Post concussion syndrome report limitations in: functional status, activities of daily living, school or work related activities, leisure and recreational activities, social interactions, financial independence Risk factors for PCS include, comorbid psychiatric illness, advanced age, heightened symptoms, intense emotions (severe anxiety) at the time of injury A patient with a blow to the head with an object, you can expect... damage to underlying tissue/vessels A patient that is thrown against a wall or solid surface, you can expect... focal and diffuse damage A patient that is punched in the face or head, you can expect...contusions/bruising/bleeding A person that experiences violent shaking of the body, you can expect: diffuse agonal injuries/torn nerve tissue A patient that falls and hits their head...you can expect: focal and diffuse damage A patient that is being strangled, you can expect...diffuse damage (hypoxia) A patient that had a near drowning, you can expect...diffuse damage (hypoxia) A patient that was shot in the face or head, you can expect...disintegration of brain tissue Chronic Traumatic Encephalopathy (CTE) a progressive, degenerative condition involving brain damage resulting from multiple episodes of head trauma 4 stages of chronic traumatic encelopathy Stage 1-patients experience depression, headaches, and short term memory loss Stage 2-difficulty controlling impulses, suicidal thoughts and severe headaches Stage 3-apathy, severe memory problems and impaired judgement Stage 4-paranoia, severe depression, aggression, dementia and suicidal behaviors -What is he fifth cranial nerve,--the trigeminal nerve, -What is the trigeminal nerve? is a large, mixed sensory and motor nerve that originates in the brainstem and travels in the cervical cord, with the sensory ganglion found in the Meckel cave in the middle cranial fossa -What is the primary feature of Trigeminal Neuralgia===recurrent paroxysms of pain in the distribution of any branch of the trigeminal nerve. The pain is usually described as burning, stabbing, sharp, penetrating, or electric shock-like and usually is on ONE SIDE OF THE FACE patient does not awaken from sleep during a paroxysm. A characteristic feature of trigeminal neuralgia is the: trigger zone, a small area of the skin or orobuccal mucosa that the patient can identify as the point that sets off an attack. Criteria for diagnosis of Trigeminal neuralgia include: • Paroxysms of pain lasting from a fraction of a second to 2 minutes and affecting one or more divisions of the trigeminal nerve without radiation of symptoms, Pain characterized as at least three events of intense, sharp, superficial, or stabbing nature and precipitated from trigger areas or trigger factors, No clinically identified neurologic deficit, Not attributable to another disorder Diagnostics include- MRI, CT, Electrophysiology testing The two major types of migraine are--migraine with aura and migraine without aura Most common type of migraine--migraine without aura Characteristics of a migraine, pounding or throbbing,moderate to severe in intensity, aggravated by PHYSICAL ACTIVITY, which is episodic, lasts 4 to 72 hours, may be associated with nausea, vomiting, photophobia, and phonophobia. common triggers of migraines include, medication overuse, obesity, depression, stressful life events, sleep problems including snoring, weather changes, foods (cheese, chocolate), alcohol, change in altitude, delay or skipping of a meal, hormonal changes. In a migraine with aura, when does the aura usually occurs: before the onset of head pain, although it can sometimes extend into the period of headache. Visual auras can also be characterized by spots, shimmering bright lights, or areas of visual loss (scotomas). A prodrome can be part of a migraine. What describes a prodrome: Several days before the aura or start of the head pain, the person may have feelings of doom or fatigue. Acute tension-type headaches are described as- feeling like there is a tight band around the head. Nausea and vomiting are NOT present, pain can be mild to moderate in intensity Most common trigger of a tension-type headache is stress. Acute tension-type headache is described as .a nagging headache that occurs FEWER than 15 days per month,is present most of the day, and may start after the person wakes up. It rarely awakens the person Chronic tension-type headache is described as: is similar in presentation to the acute type but occurs more often than 15 days per month. What are the characteristics of a cluster headache: is usually AWAKENS patients during the night with severe unilateral, retro-orbital pain. A cluster headache reaches maximum intensity in about 15 minutes and usually lasts about 90 minutes, although some can last 3 hours. Subjective examination of a patient with headache should include, The history is the most important part of the evaluation, describing the duration, quality, and location of the pain. The presence or absence of any precipitating factors, or triggers, and the age at onset should be established. The presence of associated symptoms, such as nausea, vomiting, and photophobia, should be explored. Are migraines familial? yes Physical examination should include:cardiopulmonary and complete neurologic assessment with a major focus on the following:• Funduscopic and pupillary assessment• Auscultation of the carotid and vertebral arteries• Mental status examination• Palpation of the head, neck, and temporal arteries• Evaluation for any neck stiffness, focal weakness, sensory loss and gait• Vital signs Serious symptoms and findings of a migraine include: a headache accompanied by a stiff neck; fever; malaise; nausea or vomiting; presence of any aphasia, weakness, or poor coordination Other danger signs include the following • Onset of headache after the age of 50 years • Asymmetry of pupillary responses • Decreased deep tendon reflexes • Headache described as "THE WORST EVER EXPERIENCED" • Personality change • Onset of a new or different headache • Onset of a headache that progressively worsens • Papilledema • Painful temporal arteries Lab tests for migraines include CBC, ESR, CRP, Thyroid function, Lyme titer, Rheumatoid factor, CSF cell count, Diagnostic imaging for migraines includes, CT scan, MRI*, CSF, cerebrospinal fluid; Referral for those with migraines should be made when: suspected temporal arteritis, change in mental status, nuchal rigidity, neurologic deficit, or new onset of headache-especially over the age of 50. Immediate emergency department referral for one with a migraine is indicated for: abrupt onset "THUNDERCLAP HEADACHE," trauma, or headache with associated neurologic abnormalities on physical examination Two areas of pharmacological management of migraines abortive and preventive Preventive pharmacological management is indicated when patients if they are unable to deal with their attacks, they experience MORE THAN FOUR headaches a month, or, the attacks are prolonged and refractory to medicine Abortive therapy is used to treat: the intensity and duration of pain during an attack and to manage associated symptoms, such as nausea and vomiting First line treatment of migraines include: Simple analgesics, such as acetaminophen and aspirin, can represent first-line treatment in the management of mild to moderate headaches. NSAIDS===if not relieved Corticosteroids,Triptans When simple analgesics are ineffective in treating migraines, the next step would be to: combinine them with a short-acting barbiturate, such as butalbital (Fioricet, Fiorinal, Esgic), Indications for Referral or Hospitalization for those with migraines: not easily controlled by routine headache medicines. • Rebound headaches or habituation limits outpatient therapy. • Headache is new and progressively worsening. • Headache is described as the "worse headache of my life." • Headache is affecting the patient's quality of life. • Headache is accompanied by neurologic symptoms that last longer than 30 minutes or is accompanied by numbness or hemiparesis Mild cognitive impairment (MCI) is thought to be a, transitional state between normal aging and dementia Two types of MCI, amnestic, nonamnestic, Amnestic mild cognitive impairment is characterized by deficits in memory; Nonamnestic MCI involves impairments in other cognitive functions Mild cognitive impairment or MCI is a risk factor for dementia Alzheimer disease is characterized by amyloid plaques and neurofibrillary tangles. Examinations of the brains of patients with Alzheimer disease show atrophy of the cerebral cortex that is usually diffuse but may be more pronounced in the frontal, temporal, and parietal lobes. Vascular Dementia is Multiple areas of focal ischemic change characterize vascular dementia, formerly known as multi- infarct dementia the defining lesion is the lacunar infarct. Patients with which history are particularly at risk for developing dementia hypertension, diabetes, hyperlipidemia, peripheral vascular occlusive diseases are at particular risk. Lewy body dementia is characterized by the presence of Lewy bodies in the brain.there is a loss of dopamine-producing neurons, similar to that seen in Parkinson disease, and a loss of acetylcholine, similar to that seen in Alzheimer disease. Pseudodementia--Depression in older adults can lead to memory loss, attention deficits, and problems with initiation Clinical Presentation of a patient with dementia, Memory loss, personality changes, language disturbances, problems with independent activities of daily living Clinical Presentation of a patient with Lewy body dementia visual hallucinations, motor impairments, postural instability, sleep disturbances Patients with Lewy body dementia get worse with which type of medication = Haldol Three stages of alzheimers early, middle, and late What is the initial symptom of alzheimers==short-term memory loss. The early stages of alzheimers is characterized by anxiety and depression., Word finding and naming problems may emerge as symptoms progress. The middle stage of alzheimers is characterized by a worsening of memory and language as well as judgment. Disorientation to time and place is common. There may be neuropsychiatric symptoms, including paranoia, hallucinations, and delusional thinking. Urinary incontinence may be a problem. The late stage of alzheimers is characterized by: motor rigidity, prominent neurologic abnormalities including apraxia and agnosia, severe cognitive and language impairment, death. Labs for dementia CBC, LFTs, TSH, Vitamin B12, Folate, Serum electrolytes, BUN, Creatinine, Serum glucose, Drug and alcohol levels* Diagnostics for dementia, non contrast CT, MRI The goal of management includes treatment of all correctable factors that may impair cognition to improve daily functioning and to delay disability. Activities that promote and enhance cognition and social engagement are to be encouraged. Which supplementation is recommended for those with Alzheimer's: 2000 IU of vitamin E daily is reasonable to consider in appropriate patients. Which Two classes of drugs are currently approved by the U.S. Food and Drug Administration to treat the cognitive symptoms of dementia: the cholinesterase inhibitors and N-methyl-D-aspartate (NMDA) receptor antagonists. Memantine (Namenda) is an NMDA receptor antagonist that can be used in combination with a cholinesterase inhibitor for those with moderate to severe disease these medications do not alter the course of dementia, they have been shown to delay or to slow worsening of symptoms==cholinesterase inhibitors and N-methyl-D-aspartate (NMDA) receptor antagonists. patients with dementia develop depression, which class of medications is preferred: selective serotonin reuptake inhibitors (SSRIs) Which class of medications have a "black box" warning due to increased risk of cardiovascular events when prescribing to those with dementia risperidone, olanzapine, and aripiprazol What is the focus for patient education for those with dementia to maintain independence by emphasizing patients' strengths and allowing them to continue normal activities Benzodiazepines can be utilized in all of the following scenarios except for: Group of answer choices Maria is a 22-year-old woman who has been complaining of headaches, dizziness, and memory problems. In addition, there are bruises on her neck and arms. She mentions that she is in an intimate relationship with someone who has a bad temper. What is NOT an appropriate approach for the screening of traumatic brain injury in this patient? Immediate Post-Concussive Assessment and Cognitive Testing (ImPACT) Which of the following is NOT an overlapping symptom of Post Traumatic Stress Disorder (PTSD) and Persistent Post Concussive Syndrome (PPCS): (TBI) medication cause paradoxical agitation? Different head injuries and what they cause: symptoms, intense emotions (severe anxiety) at the time of injury A patient with a blow to the head with an object, you can expect... damage to underlying tissue/vessels A patient that is thrown against a wall or solid surface, you can expect... focal and diffuse damage A patient that is punched in the face or head, you can expect... contusions/bruising/bleeding A person that experiences violent shaking of the body, you can expect diffuse agonal injuries/torn nerve tissue A patient that falls and hits their head...you can expect focal and diffuse damage A patient that is being strangled, you can expect... diffuse damage (hypoxia) A patient that had a near drowning, you can expect... diffuse damage (hypoxia) A patient that was shot in the face or head, you can expect... disintegration of brain tissue "Which type of medication may be particularly dangerous when treating aggression in patients with traumatic brain injury (TBI) because it could cause paradoxical agitation?" 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