Kaylas Medsurg Review Flashcards
(222 cards)
1
Q
What is the priority assessment in nursing care?
A
Assessment vs Implementation
Nurses must assess the client’s condition and determine if goals and outcomes were met before implementing care.
2
Q
What does ABCS stand for in nursing priorities?
A
Airway, Breathing, Circulation
These are the primary considerations for patient assessment and intervention.
3
Q
What position should a patient with shortness of breath assume?
A
High Fowler’s position
This position helps alleviate respiratory distress.
4
Q
What is the most acute condition to prioritize in nursing care?
A
Acute exacerbation, pulmonary emboli
These conditions require immediate attention due to their life-threatening nature.
5
Q
Fill in the blank: A patient with spinal cord injury is at risk for urinary retention and should be approached with _______ first.
A
least invasive interventions
6
Q
What are the early signs of increased intracranial pressure (ICP)?
A
Change in level of consciousness
Early detection of ICP changes is critical for patient safety.
7
Q
Which cranial nerve is responsible for eye movement and is assessed by asking a client to look up and down?
A
Cranial nerve 3 (Oculomotor nerve)
This nerve is crucial for motor control of the eye.
8
Q
What is the expected urinalysis finding in a patient with diabetes insipidus?
A
Decreased specific gravity
This indicates diluted urine due to insufficient antidiuretic hormone.
9
Q
What is the most important action for a patient reporting constipation after surgery?
A
Encouraging bowel movement frequency and characteristics
Assessing bowel habits is essential for patient education and management.
10
Q
True or False: The left cerebral hemisphere is associated with language and problem-solving.
A
True
11
Q
What is the nursing intervention for a patient experiencing a tonic-clonic seizure?
A
Move client to a flat surface and turn to side
This prevents aspiration and injury during a seizure.
12
Q
What dietary recommendation is important for a patient with diverticulosis?
A
Increase fiber intake
Fiber helps regulate bowel movements and prevents complications.
13
Q
What is a key intervention for a patient with pneumonia?
A
Improving airway patency
This may include hydration, coughing exercises, and chest physiotherapy.
14
Q
What is a potential complication of asthma?
A
Respiratory failure
Persistent hypoxemia can lead to this serious condition.
15
Q
What is the priority assessment before administering t-PA for an ischemic stroke?
A
Time of onset symptoms
Timeliness is critical for effective treatment of strokes.
16
Q
Fill in the blank: The greatest risk for seizure activity is in a patient with a recent _______.
A
head injury
17
Q
What should the nurse do for a patient showing signs of increased ICP?
A
Monitor for unequal pupil size
This can indicate serious complications such as bleeding in the brain.
18
Q
Which patient population is at risk for Hepatitis A?
A
Individuals with poor hand hygiene and food handling practices
Vaccination and education are key preventive measures.
19
Q
What is a common sign of a pneumothorax?
A
Dyspnea and anxiety
These symptoms arise due to impaired lung function.
20
Q
What should be monitored in a patient with a history of diabetes who has stopped taking medication?
A
Understand the patient’s reasoning for stopping medication
This helps address potential barriers to adherence.
21
Q
What is the nursing action for a patient with COPD who is drowsy and unable to expectorate secretions?
A
Perform nasotracheal suctioning
This is crucial for maintaining airway patency.
22
Q
What is the primary goal for a patient with a spinal cord injury at level L5?
A
Independent ambulation without equipment
This is a key rehabilitation goal for enhancing quality of life.
23
Q
What are the signs of Cushing’s triad in increased ICP?
A
High systolic BP, bradycardia, bradypnea
These signs indicate a critical state requiring immediate intervention.
24
Q
What is the risk factor for acute pancreatitis?
A
Alcohol and high-fat diet
These lifestyle factors significantly contribute to the condition.
25
What is the PaO2 level indicating hypoxemia?
<80mmHg
26
What are the main types of anticoagulants mentioned?
* Enoxaparin (Lovenox)
* Heparin
* Warfarin (Coumadin)
* Xarelto
27
What is the purpose of anticoagulants?
Prevents clots from getting bigger or more clots forming
28
What are the contraindications for anticoagulants?
* CVA
* Bleeds
* PUD
29
What lab tests should be assessed with anticoagulants?
* PTT
* PT
* INR
30
What are some side effects of anticoagulants?
Bleeding
31
What are the two thrombolytic therapies mentioned?
* Alteplase (Activase)
* Streptokinase (Streptase)
32
What should be monitored during thrombolytic therapy?
Side effects
33
What should patients and families be educated about regarding immobility?
Avoid immobility
34
Which foods should be avoided to reduce the effects of Coumadin?
High Vitamin K foods (green leafy vegetables)
35
What are some invasive/surgical interventions for clot management?
* Embolectomy
* Vena Cava Filter
36
What are complications associated with acute right-sided heart failure?
Cardiogenic shock, BP decreases
37
What is Peripheral Vascular Disease (PVD)?
Deoxygenated blood can’t go back to the heart
38
What are risk factors for venous thromboembolism (VTE)?
* Impaired mobility
* Pregnancy
* Heart Failure
39
What are the signs and symptoms of PVD?
* Dull, constant achy pain
* Edema
* Warm legs
* Status dermatitis (brown/yellow)
* Venous stasis ulcers
40
What diagnostic test is used for assessing DVT?
D-dimer (normal <250)
41
What medications are used in the nursing care of PVD?
* Anticoagulants (aspirin or clopidogrel)
* Statins
42
What should patients be educated about to manage PVD?
* Avoid long sitting/standing
* Walk frequently
* Use elastic supports
* Avoid constrictive clothing
43
What is the definition of Peripheral Artery Disease (PAD)?
Narrow artery (atherosclerosis) where oxygenated blood can’t get to the distal extremities
44
What are the signs and symptoms of PAD?
* Numbness/cramping/pain in legs
* Swelling of legs
* Intermittent claudication
45
What are the risk factors for PAD?
* Hypertension
* Hyperlipidemia
* Diabetes
* Obesity
46
What are the complications of PVD?
* Ulcer formation
* Pulmonary embolism
47
What is coronary artery disease (CAD)?
Decreased O2 supply to myocardium, decreased coronary blood flow
48
What are the risk factors for CAD?
* Age
* Gender
* Family hx
* Diabetes
* Hyperlipidemia
* Hypertension
* Smoking
* Obesity
49
What are the treatments for CAD?
* Increase HDL
* Decrease total cholesterol and LDL
* Smoking cessation
* Stress management
* CABG
50
What is angina?
Chest pain indicating myocardial ischemia due to O2 demand exceeding supply
51
What differentiates stable angina from unstable angina?
Stable angina is predictable and relieved by rest, while unstable angina is unrelieved by rest and has a higher risk for MI
52
What initial treatments are used for myocardial infarction (MI)?
* Morphine
* Oxygen
* Nitroglycerin
* Aspirin
53
What are the complications of myocardial infarction?
* Dysrhythmias
* Heart failure
* Cardiogenic shock
54
What is heart failure?
Heart muscle unable to pump effectively, leading to inadequate cardiac output
55
What are common assessments for left-sided heart failure?
* Orthopnea
* Fatigue
* Dyspnea
* Cough
56
What are common assessments for right-sided heart failure?
* JVD
* Edema
* Ascites
57
What are the primary nursing interventions for heart failure?
* Monitor I&O and daily weights
* Assess for SOB
* Monitor VS and hemodynamic pressures
58
What diagnostic tests are used for heart failure?
* Hemodynamic monitoring
* CXR
* TEE
59
What is the normal ejection fraction (EF)?
50% - 70%
60
What is the purpose of a pacemaker?
To regulate heart rhythm in cases of bradycardia, tachycardia, or post-operative management
61
What are the complications of pacemakers?
* Failure to fire
* Infection
* Hematoma
62
What should patients be educated about regarding pacemakers?
* Monitor ECG
* Avoid radiation
* Inform airport security
63
What is the significance of the QT segment on an ECG?
May be prolonged due to medication
64
What are the signs of fluid excess?
* Confusion
* Hypertension
* Pitting edema
* Dyspnea
65
What are common nursing interventions for fluid excess?
* Monitor vital signs
* Assess for neurological changes
* Daily weights
66
What are common neurological symptoms of fluid overload?
Altered LOC, muscle weakness/twitching, seizures, headache
## Footnote
LOC = Level of Consciousness
67
What cardiovascular symptoms indicate fluid overload?
Hypertension, bounding pulse (+4), pitting edema, distended neck & hand veins, tachycardia, S3 murmur
## Footnote
S3 murmur indicates possible heart failure.
68
List respiratory symptoms associated with fluid overload.
Dyspnea, shortness of breath, tachypnea, crackles on auscultation
69
What gastrointestinal symptoms are signs of fluid overload?
Weight gain, increased motility, ascites
70
How does fluid overload affect urinary output?
Increased amount of clear urine if overhydrated; decreased amount of urine if retention
71
What integumentary symptoms are associated with fluid overload?
Pitting edema, pale, cool to touch
72
What is a common nursing intervention for fluid overload?
Daily weight monitoring
73
What are the key dietary considerations for managing fluid overload?
Fluid restriction vs. sodium restriction
74
What medications might be prescribed for fluid overload?
Diuretics as prescribed
75
What neurological symptoms indicate fluid volume deficit?
Dizziness, decreased CNS activity, skeletal muscle weakness, hyperactive deep tendon reflexes
76
What cardiovascular signs and symptoms are present in fluid volume deficit?
Hypotension, orthostatic hypotension, thready pulse (+1), tachycardia, flat neck veins when supine, possible fever
77
What are common respiratory symptoms in fluid volume deficit?
Tachypnea
78
What gastrointestinal symptoms are associated with fluid volume deficit?
Thirst, dry mucous membranes, acute weight loss, constipation, decreased motility
79
What urinary output is considered oliguria?
Decreased production of urine < 30 mL/hr
80
What are the normal arterial blood gas values for pH?
7.35-7.45
81
What is the normal range for HCO3?
22-26 mEq/L
82
How does acidosis affect pH?
In acidosis, the pH is decreased
83
What is the respiratory indicator in acid-base balance?
PaCO2
84
What is the metabolic indicator in acid-base balance?
HCO3-
85
Define respiratory acidosis.
pH <7.35, pCO2 > 45 mm Hg, PaO2 < 80
86
What are common causes of respiratory acidosis?
* Hypoventilation * Pneumonia * Atelectasis * COPD * Respiratory failure * Airway obstruction * CNS depression
87
What symptoms are associated with respiratory acidosis?
* Confusion * Dyspnea * Dizziness * Lethargy * Unconsciousness * Dysrhythmias
88
How is respiratory acidosis treated?
* Improve ventilation * Oxygen therapy * Coughing and deep breathing * Hydration * Chest physiotherapy * Mechanical ventilation
89
Define respiratory alkalosis.
pH >7.45, pCO2 < 35 mm Hg
90
What are common causes of respiratory alkalosis?
* Hyperventilation * Extreme anxiety * Hypoxemia * High fever * Early sepsis * CNS lesion
91
What symptoms are associated with respiratory alkalosis?
* Tachypnea * Dizziness * Confusion * Lightheadedness * Numbness and tingling in extremities * Coma * Seizures
92
How is respiratory alkalosis treated?
Encourage breathing into a paper bag and breathe slowly and deeply
93
Define metabolic acidosis.
pH < 7.35, HCO3 < 22
94
What are common causes of metabolic acidosis?
* Diabetic ketoacidosis (DKA) * Renal failure * Starvation * Diarrhea * Intestinal fistula * Shock * Vomiting or gastric suction
95
What symptoms are associated with metabolic acidosis?
* Tachypnea with deep respirations (Kussmaul’s respiration) * Headache * Drowsiness * Confusion * Abdominal cramps * Nausea and vomiting
96
How is metabolic acidosis treated?
* Depends on the underlying cause * Sodium bicarbonate * Insulin and IV fluids for DKA * Dialysis for renal failure * IV fluids for dehydration and starvation * Antibiotics and IV fluids for sepsis * Monitor for hyperkalemia
97
Define metabolic alkalosis.
pH > 7.45, HCO3 > 26
98
What are common causes of metabolic alkalosis?
* Excessive ingestion of alkali like Na Bicarbonate * Vomiting * Gastric drainage * Hypokalemia * Potassium-wasting diuretics
99
How is metabolic alkalosis treated?
Treat underlying cause: administer NaCl fluids, monitor for hypokalemia
100
What are normal sodium levels?
135-145 mEq/L
101
What are normal potassium levels?
3.5-5 mEq/L
102
What are normal calcium levels?
9-10.5 mg/dL
103
What are normal magnesium levels?
1.3-2.1 mEq/L
104
What are normal BUN levels?
6-20 mg/dL
105
What are normal creatinine levels?
0.8 to 1.2 mg/dL
106
What is the nursing care for hypernatremia?
Neuro (FVD), hypotonic IV fluids
107
What is the nursing care for hyponatremia?
Neuro, isotonic/hypertonic fluids
108
What are symptoms of hyperkalemia?
Cardiac dysrhythmias, increased peristalsis, ST elevation
109
What are treatments for hyperkalemia?
* Kayexalate * Restrict potassium * Diuretics (Lasix) * Calcium gluconate
110
What are symptoms of hypokalemia?
Constipation, beware with lithium toxicity
111
What are treatments for hypokalemia?
Potassium - never IV push
112
What are symptoms of hypercalcemia?
Restrict calcium, IV phosphate
113
What are symptoms of hypocalcemia?
* Tremors * Chvostek's sign * Trousseau's sign * Increased DTRs * Seizure and fall precautions
114
What is the treatment for hypocalcemia?
Diuretics, calcium gluconate
115
What are treatments for hypermagnesemia?
Respiratory support, calcium gluconate, diuretics
116
What is the treatment for hypomagnesemia?
Respiratory support, magnesium replacement (whole grain, leafy greens)
117
What is diabetes type 1 characterized by?
Lack of insulin, complication = DKA
118
What is diabetes type 2 characterized by?
Impaired insulin release, complication = HHS
119
What are the three symptoms of osmotic diuresis in diabetes?
* Polyuria * Polydipsia * Polyphagia
120
What is DKA?
Major crisis for those with T1D, patient produces NO insulin
121
What are risk factors for DKA?
* Undiagnosed/unmanaged T1D * Missed dose of insulin * Stress * Infection * Illness * Trauma
122
What are the signs and symptoms of DKA?
* Kussmaul respirations * Blurred vision * Orthostatic hypotension * Headache * Fruity breath * Dehydration (3 P's) * Ketones in urine * Weight loss * N/V * BG > 300
123
What diagnostics are used for DKA?
* BMP (Na ^, BUN/Cre ^, K ^) * Serum osmo ^ * ABG (pH low)
124
What is the treatment for DKA?
* Frequent labs * Risk for hypokalemia with large doses of insulin * IVF (fluid → push → drip) * Only regular insulin IV
125
What is hypothyroidism characterized by?
Not enough T3 and T4, slowing of all body functions
126
What are risk factors for hypothyroidism?
* Genetics/females * H/O thyroidectomy * Too much hyperthyroid drugs * Iodine deficiency * Hashimoto's disease * Radiation therapy
127
What are signs and symptoms of hypothyroidism?
* Malaise * Fatigue * Weakness * Depression * Weight gain * Alopecia * Dry flaky skin * Irregular menses * Constipation * Low HR/RR/BP * Dry thin hair * Decreased DTR
128
What is the treatment for hypothyroidism?
Synthroid - taken for life
129
What are the potential complications of Synthroid?
* Heart failure/MI * Osteoporosis * Insomnia
130
What are signs and symptoms of myxedema coma?
* Hypoventilation * Hypothermia * Hypotension
131
What is hyperthyroidism characterized by?
Too much T3 and T4, all body functions FAST
132
What are risk factors for hyperthyroidism?
* Too much levothyroxine * Pituitary tumor/thyroid cancer
133
What are signs and symptoms of hyperthyroidism?
* Fatigue * Nervousness * Anxiety * Insomnia * Weight loss * Facial flushing * Exophthalmos * Diarrhea * Tremor * Goiter * Diaphoresis * Thin soft fine hair * Increased DTR
134
What are the diagnostics for hyperthyroidism?
* Thyroid panel (T3/T4) → will be high * TSH will be low * Radioactive iodine uptake test
135
What is the treatment for hyperthyroidism?
* Lugol’s SSKI * PTU * Methimazole * Inderal/Propranolol
136
What is Addison's disease?
Adrenal hypofunction, all three classes (sex, sugar, salt) are reduced
137
What are signs and symptoms of Addison's disease?
* Fatigue * Weight loss * Hypoglycemia * Dehydration * Muscle weakness * Bronze/brown skin * Hypotension
138
What are the diagnostics for Addison's disease?
* Low blood glucose * Low Na * High K * High Ca
139
What is the treatment for Addison's disease?
* IVF * IV hydrocortisone/dexamethasone * Hyper K management
140
What is Cushing’s syndrome?
Adrenal hyperfunction, excess production of corticosteroids
141
What are risk factors for Cushing’s syndrome?
* ACTH secreting adenoma * High doses of steroids
142
What are signs and symptoms of Cushing’s syndrome?
* Moon face * Truncal obesity * Buffalo hump * Striae of abdomen * Weight gain only on stomach * Menses disorder * Easily bruised * Acne * Facial hair * Muscle weakness * Osteoporosis * Masculine/hirsutism
143
What is the treatment for Cushing’s syndrome?
* Usually an adrenalectomy * Symptom management * Taper off steroids * Ketoconazole lowers steroids
144
What is gastritis?
Inflammation of gastric mucosa
145
What are risk factors for gastritis?
* Aspirin * NSAID use * Alcohol * Infection * Illness * H. Pylori
146
What are signs and symptoms of gastritis?
* Dyspepsia * Bleeding * Black tarry stools * Abdomen tender * Blood in stool/vomit
147
What diagnostics are used for gastritis?
* CBC w diff * Breath test for H. Pylori * Guaiac for stool * Upper endoscopy (EGD)
148
What are the treatments for gastritis?
* Optimal nutrition * Promote F/E imbalance * Relieve pain with diet, meds, B12 injections if anemic
149
What is a potential complication of gastritis?
Bleeding
150
What is EGD?
Esophagogastroduodenoscopy
## Footnote
A procedure used to diagnose conditions like H. Pylori and cancer.
151
What is the NPO requirement before EGD?
6-8 hours prior.
152
What are the nursing interventions for a patient undergoing treatment for gastric issues?
* Optimal nutrition
* Promote fluid/electrolyte imbalance monitoring
* Relieve pain with diet and medications
* Monitor for signs of upper gastrointestinal bleeding.
153
What are the signs of upper gastrointestinal bleeding?
* Anemia
* Hematemesis
* Melena
* Occult blood
* Tachycardia
* Hypotension.
154
What is gastric outlet obstruction?
Characterized by continuous vomiting, bloating, and nausea.
155
What complications can arise from gastric issues?
* Bleeding
* Dehydration
* Pernicious anemia
* Dumping syndrome.
156
What is GERD?
Gastroesophageal reflux disease, which is the reflux of stomach contents into the esophagus.
157
What are the risk factors for GERD?
* Increased age
* Obesity
* H. Pylori
* Spicy foods
* Alcohol
* Large meals
* Smoking.
158
What are the symptoms of GERD?
* Dyspepsia (heartburn)
* Regurgitation
* Cough
* Hoarseness
* Wheezing.
159
What is peptic ulcer disease?
Ulceration of the gastric mucosa, esophagus, or duodenum.
160
What are the risk factors for peptic ulcer disease?
* H. Pylori
* Genetics
* NSAID use
* Stress
* Diet
* Alcohol.
161
How is peptic ulcer disease diagnosed?
Through EGD.
162
What is the treatment regimen for peptic ulcer disease?
* Omeprazole
* Clarithromycin
* Amoxicillin
* Followed by PPI.
163
What nursing interventions are important for patients with peptic ulcer disease?
* Monitor vital signs
* Prevent shock with IV fluids
* Assess for complications like dumping syndrome.
164
What is diverticulitis?
Sac-like herniation of the bowel.
165
What are the risk factors for diverticulitis?
* Low fiber diet
* Lack of exercise
* Inadequate water intake.
166
What are the symptoms of diverticulitis?
* Acute, severe LLQ pain
* Fever
* Chills
* Nausea/vomiting
* Bloody stools.
167
What are the complications of diverticulitis?
* Abscess
* Perforation
* Peritonitis.
168
What are the classic signs of appendicitis?
* Abdominal pain starting around the periumbilical area that radiates to the RLQ.
* McBurney's point tenderness.
* Rebound tenderness.
169
What are the risk factors for liver failure/cirrhosis?
* Alcohol abuse
* Hepatitis (especially C)
* Fatty liver disease.
170
What are the early signs of liver failure?
* Anorexia
* Nausea/vomiting
* Changes in bowel habits
* Pruritus
* Hepatomegaly.
171
What are the late signs of liver failure?
* Jaundice
* Altered level of consciousness
* Ascites
* Depression.
172
What are the complications of liver failure?
* Jaundice
* Portal hypertension
* Ascites
* Esophageal varices
* Hepatic encephalopathy.
173
What is pancreatitis?
Autodigestion of the pancreas.
174
What are the risk factors for pancreatitis?
* Alcohol consumption
* High-fat diet
* Bile disease.
* Increased triglycerides.
175
What are the symptoms of pancreatitis?
* Severe sudden LUQ pain radiating to the back
* Low-grade fever
* Tachycardia
* Jaundice.
* Steatorrhea.
176
What are the complications of pancreatitis?
* Disseminated Intravascular Coagulation (DIC)
* Pancreatic infection
* Multiple Organ Dysfunction Syndrome (MODS).
177
What is cholecystitis?
Inflammation of the gallbladder.
178
What are the risk factors for cholecystitis?
* Female
* Fat
* Fertile
* Forty.
179
What is the Murphy sign?
Pain on palpation of the RUQ during inspiration.
180
What are the early signs of increased intracranial pressure?
* Change in level of consciousness
* Confusion
* Restlessness
* Constant headache.
181
What are the late signs of increased intracranial pressure?
* Continued deterioration in consciousness
* Decreased pulse and respiratory rate
* High blood pressure and temperature.
* Cushing's Triad.
182
What is status epilepticus?
Acute prolonged seizures without full recovery between attacks.
183
What are the complications of seizures?
* Hypoxia
* Cardiac dysrhythmias
* Respiratory arrest
* Cerebral anoxia and edema.
* Irreversible brain damage.
184
What is an epidural hematoma?
Rapid blood collection between the skull and dura mater.
185
What are the signs of an epidural hematoma?
* Brief loss of consciousness
* Progressing to confusion and coma.
186
What is a subdural hematoma?
Blood collection between the dura mater and the brain due to trauma.
187
What are the signs of a chronic subdural hematoma?
* Severe headache
* Personality changes
* Focal seizures.
188
What is an intracerebral hemorrhage?
Bleeding within the brain due to trauma or systemic issues.
189
What are the signs of an intracerebral hemorrhage?
* Subtle symptoms
* 'Worst headache of my life.'
190
What is a subarachnoid hemorrhage?
Bleeding into the subarachnoid space.
191
What are the signs and symptoms of Acute intracerebral hemorrhage?
Change in LOC, pupillary signs
## Footnote
LOC refers to Level of Consciousness
192
What are the signs and symptoms of Chronic intracerebral hemorrhage?
Severe headache, personality changes, focal seizures.
193
What can cause Intracerebral Hemorrhage?
Penetrating trauma, uncontrolled hypertension, aneurysm rupture.
194
What is Subarachnoid Hemorrhage?
Bleeding into the space surrounding the brain tissue.
195
What are the two types of Stroke/CVA?
* Ischemic
* Hemorrhagic
196
What is the main cause of Brain Ischemia?
Clot (e.g., Afib and Valve disease).
197
What are the general risk factors for stroke?
* Diabetes Mellitus (DM)
* Hypertension (HTN)
* Hyperlipidemia (HLD)
* Smoking
* Gender
* Lack of exercise
* Atrial Fibrillation (AFIB)
198
What are the signs and symptoms of Brain Ischemia?
* Numbness/weakness on one side of the body
* Visual issues
* Gait issues
* Speaking issues
* Mental status change
199
What are the signs and symptoms of Brain Hemorrhage?
* Headache
* Sluggish pupil response
* Loss of LOC
* Uncontrolled BP
* Vomiting
* Seizure
200
What is the main diagnostic tool for stroke?
Head CT less than 25 minutes of arrival.
201
What does 'BE FAST' stand for in stroke assessment?
* Balance
* Eyes (blurred vision, pupillary changes)
* Face
* Arms
* Speech
* Time
202
What is one preventative measure for stroke?
DASH diet.
203
What is the first-line treatment for Brain Ischemia?
Anticoagulants.
204
What is the main goal in treating Brain Hemorrhage?
Decrease ICP (Intracranial Pressure).
205
What should be checked before giving food to a patient after a stroke?
Gag reflex.
206
What can indicate a Basilar skull fracture?
Raccoon eyes, rhinorrhea, otorrhea CSF leaks from eyes and ears.
207
What are the signs of a Traumatic Brain Injury?
* Focal injuries: contusion, laceration, intracerebral hemorrhage, hematomas
* Diffuse injuries: concussions, diffuse axonal injuries
208
What is a common complication of a spinal cord injury?
Paralysis.
209
What does the term 'Autonomic Dysreflexia' refer to?
Excessive fluctuations of the autonomic nervous system.
210
What are the signs and symptoms of Autonomic Dysreflexia?
* Severe HTN
* Abnormal breathing
* Excess sweating
* Temperature fluctuations
* Decreased heart rate
211
What is the first-line medication for treating Parkinson's Disease?
Levodopa.
212
What are the main signs and symptoms of Parkinson's Disease?
* Resting tremors
* Rigidity
* Bradykinesia (shuffling gait)
* Postural instability
213
What is a key diagnostic criterion for Parkinson's Disease?
Must have 2 of 4: resting tremors, rigidity, bradykinesia, postural instability.
214
What complications can arise from Parkinson's Disease?
* Aspiration
* Pneumonia
* Orthostasis
* Decreased oral intake
* Fall risk
215
What are the goals of nursing care for patients with spinal cord injuries?
* Assess respiratory status
* Assess LOC, motor function, PERRLA, and reflexes
* Check for Cushing’s Triad
216
What is the goal for cervical spine injuries?
Wheelchair bound.
217
What is the goal for lumbar spine injuries?
Independent ambulation without equipment.
218
What is a common medication used to manage hypertension in Autonomic Dysreflexia?
* Nifedipine
* Labetalol
* Hydralazine
* Nitrates
219
What does 'Decorticate posturing' indicate?
Damage to corticospinal tract.
220
What does 'Decerebrate posturing' indicate?
Damage to brain stem.
221
What is the most important nursing assessment for a patient with a cervical spinal injury?
Respiratory status.
222
What are the diagnostics for spinal cord injuries?
* CT Angio
* MRI
* PET
* EEG
* EMG
