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NUR 176 FINAL QUESTIONS AND ANSWERS
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NUR 176 FINAL QUESTIONS AND ANSWERS
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NUR 176 FINAL QUESTIONS AND ANSWERSWhat three components does the glasgow coma scale measure? - answers -eye
response
Verbal response
Motor response
Earliest sign of icp? - answers -change in loc
Headache
Do you perform a lumbar puncture on a patient with increased icp? - answers -no
What is decorticate posturing? - answers -abnormal flexion:
Hands pulled to chest and hyper-extended.
Internal rotation and adduction of the arms with flexion of the elbows, wrists & fingers.
"flexor - toward the cord"
What is deceberate posturing? - answers -outward rotation of upper extremities hands
flexed out at sides.
What is focal seizures? - answers -pt will appear awake but can't respond
Usually less than 3 minutes
An aura usually occurs after (focal seizure that affects cortex but doesn't cause
unconsciousness)
What happens during a tonic- clonic seizure? - answers -stiffness
Loss of consciousness
May be incontinent of urine
Last about 2-3 minutes
What is the postictal phase? - answers -time period immediately following cessation of
seizure activity
What are absent seizures? - answers -staring spell, usually only last 5-10 seconds
What are clonic seizures? - answers -rhythmic jerking motor movements
What are myoclonic seizures? - answers -chraracterized by quick, nonrhythmic, shock-
like muscular contractions that can occur in rapid succession and usually are not
associated with impaired consciousness (typical of juvenile myoclonic epilepsy)
What are atonic seizures? - answers -sudden loss of muscle tone in legs, causes pt to
collapse
Is delirium sudden or gradual onset? - answers -sudden
, Is delirium reversable? - answers -yes
Is dementia sudden or gradual onset? - answers -gradual
Is dementia reversable? - answers -no
S/s of delerium - answers --rapid onset (hours to days)
-fluctuating course with more confusion at night
-intermittent memory loss
-reduced level of consciousness
-decreased awareness of surroundings
-inability to maintain attention or focus
-impaired cognition (concentration, judgement, communication, perception)
-incoherent speech
-increase or decrease in psychomotor activity
-hallucinations (usually visual) and illusions
-fleeting, poorly organized delusional thoughts
-involuntary tremors or movements
-appetite and sleep disturbances
S/s of dementia - answers -short and/or long term memory loss; impaired judgement;
personality changes; abnormalities of speech; impaired ability to perform adls
What is cushing's triad? - answers -irregular respirations, systolic hypertension with a
widening pulse pressure, slow full bounding pulse
What does befast stand for? - answers -b: balance
E: eyes
F: face
A: arms
S: speech
T: time
What are the 2 types of strokes? - answers -ischemic and hemorrhagic
What is ischemic stroke? - answers -a clot blocks blood flow to an area of the brain
What is a hemorrhagic stroke? - answers -a stroke caused by bleeding into the brain
What is aphasia? - answers -loss of ability to understand or express speech
What is receptive aphasia? - answers -inability to understand written or spoken
language
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