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NUR 436 Exam 2 Questions with Complete Solutions
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NUR 436 Exam 2 Questions with Complete Solutions
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NUR 436 Exam 2 Questions withComplete Solutions
Bacterial Meningitis - Answer-Patho: acute inflammation of meninges; bacteria causes
inflammation and exudate to accumulate in the SUBARACHNOID space leading to
obstruction of CSF flow and increased ICP
CM: seizures, pain, infants (HIGH-PITCHED CRY, BULGING FONTANEL), children
>2yrs (change in mental status, NUCHAL RIGIDITY, POSITIVE KERNIG AND
BRUDZINSKI SIGNS, photophobia), fever
Diagnostics: LP of CSF- appears cloudy with high WBC, HIGH PROTEIN, LOW
GLUCOSE, gram stain and culture will identify organism
Nursing dx: risk for infection, decreased cerebral adaptivity, risk for injury (seizures)
Nursing care: s/sx of infection, monitor Na/urine, assess neuro status/seizures, elevated
HOB with head midline, cluster care to decrease stimuli, seizure precautions; monitor
pain, comfort measures, cool bath
Therapeutic management: droplet precautions for 24 hours, corticosteroid
(dexamethasone) to decrease inflammation, seizures- antiepileptics, cerebral edema tx
Quality outcomes: early recognition of s/sx, abx administered as soon as dx is
established, cerebral edema prevented, exposure prevented by early isolation, SE
managed, neurologic sequalae prevented
Viral Encephalitis - Answer-Patho: acute inflammatory process of the brain
CM: poor feeding and anorexia, headache, NUCHAL RIGIDITY, tremors, ataxia, speech
difficulties, severe cases (increased ICP, decreased LOC, seizures, ocular palsies,
paralysis
Diagnostics: CT/MRI, LP
Nursing dx: risk for infection, decreased cerebral adaptivity, risk for injury (seizures),
IMPAIRED MOBILITY
Nursing care: s/sx of infection, monitor seizures, pain, assess neuro, elevated HOB with
head midline, cluster care to decrease stimuli, seizure precautions, ASSESS FALL
RISK, MOBILITY , BRADEN Q, ALTERNATE COMMUNICATION MEANS, TURN
Q2HR
Therapeutic management: IV/NG feeds and hydration, ANTIVIRAL AGENT (HERPES
SIMPLEX ONLY), prevent long term disabilities, PT/OT/speech
Quality outcomes: early recognition and s/sx of meningitis, cerebral edema prevented,
SE managed, neurologic sequalae prevented
Reye Syndrome - Answer-Patho: acute METABOLIC ENCEPHALOPATHY D/T
MITOCHONDRIAL DYSFUNCTION -> FATTY ACID METABOLISM DISTURBANCES -
> FATTY LIVER (DYSFUNCTION) -> CEREBRAL EDEMA
CM: fever, PROFUSE VOMITING, profound impaired consciousness with pathological
cerebral edema
Diagnostics: CT, hepatic lab levels (increased PT, PTT, AST, ALT, NH4), palpable
hepatomegaly, liver biopsy performed
, Nursing dx: impaired comfort/fluid volume deficit, decreased cerebral adaptivity, risk for
injury (seizures), RISK FOR INJURY (BLEEDING)
Nursing care: monitor temp/VS, I&O, seizures, assess neuro, elevated HOB with head
midline, seizure precautions, cluster care, MONITOR FOR S/SX OF BLEEDING,
BLEEDING PRECAUTIONS (NO RECTAL TEMSP, ENEMAS, NO IM MEDS), USE
TOOTHETTES
Therapeutic management: antipyretic/antiemetic- IVF PRN, prevent long term
disabilities ,seizure meds, cerebral edema tx, NO NSAIDS, monitor hepatic lab levels
Spina Bifida Occulta - Answer-Midline defect involving failure of the osseous spine to
close, but not visible externally
Meningocele - Answer-Hernial protrusion of a saclike cyst of meninges filled with spinal
fluid
Anecephaly - Answer-Absence of cerebral hemisphere, incompatible with life
Myelomeningocele - Answer-Patho: hernial protrusion of a saclike cyst containing
meninges, spinal fluid, and a portion of the spinal cord with its nerves
CM: flaccid, partial/full paralysis of LE with decreased sensation,
KYPHOSIS/SCOLIOSIS, hydrocephalus, overflow incontinences (risk for neurogenic
bladder), lack of bowel control/constipation
Nursing dx: impaired physical mobility/skin integrity, decreased cerebral adaptivity, risk
for injury (seizures), impaired urinary elimination with risk for infection, constipation
Nursing care: ASSESS SKIN WITH BRADEN Q, ASSESS MOBILITY STATUS AND
TURN Q2HR, USE LOTION ON SKIN, USE PLAY/PROM/UPRIGHT POSITIONING,
encourage hydration, monitor VS/ seizures, assess neuro, elevate HOB with head
midline, seizure precautions, TEACH/PERFORM STRAIGHT CATH, monitor s/sx of
UTI, encourage hydration, ASSESS SKIN FOR DERMATITIS, ENCOURAGE
REGULAR TOILETING AND DEITARY FIBER, hydration, monitor stool
Therapeutic management: orthopedic/musculoskeletal consult to prevent/correct
deformities, UTI (antipyretic, abx, VCUG, BLADDER SPASMS= OXYBUTYNIN),
DERMATITIS= BARRIER CREAM, bowel regimen (laxatives- polyethene glycol,
enemas)
Cerebral Palsy (CP) - Answer-Patho: non-progressive disorder of posture and
movement, STATIC BRAIN INJURY, spastic (pyramidal) quadriplegia is the most
common
CM: poor fine motor skills which may include speech/difficulty swallowing,
PERSISTENCE OF PRIMITIVE INFANTILE REFLEXES (TONIC NECK AND
BABINSKI), abnormal reflexes with scissoring in supine position
Diagnostics: MRI, movement assessment, EEG
Nursing dx: impaired communication, impaired physical mobility, risk for injury (seizures,
falls), impaired comfort/chronic pain
Nursing care: assess communication ability, neuro status and seizure activity, fall risk
assessment, assess pain and comfort, use distraction
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