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NUR2214 Exam 3|70 Questions with Answers 2024
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NUR2214 Exam 3|70 Questions withAnswers 2024
Body systems involved in has exchange - -neurologic
respiratory
cardiovascular
-labs indicative of impaired gas exchange - -ABG
CBC
Sputum Exam
Skin tests
Pathologic analysis
-S/S of adequate ventilation - -breathing is quiet and effortless
sat 95-100
skin, nail beds, lips are appropriate color
thorax is symmetric with equal thoracic expansion bilaterally
spinous processes are in alignment;scapulae are bilaterally symmetric
AP is less than transverse
trachea is midline
breath sounds are clear
-NI for increased ICP - -elevate HOB to 30 degrees
distribute care
only suction when needed
hyperventilation (decreases perfusion, only short-term intervention)
bowel management ( stool softeners, laxatives)
-assessment of increased ICP - -sustained or equal to 20
s/s:
headache
decreased LOC
N/V
CN 6 palsies (inability to turn the eye laterally outward)
papilledema
periorbital bruising
late sign: cushings triad: hypertension, bradycardia, irregular breathing
-Fibrinolytic therapy indications: - -after an acute ischemic stroke
4.5 hours after
unless:
older than 80
anticoagulation less than or equal to 1.7
NIHSS > 25
, Hx of diabetes and stroke
-how to give fibrinolytic therapy: - -dosage based on weight
perform double check of glucose
programmable pump, initial dose is 0.9mg/kg (max dose of 90mg) ocer 60
mins with 10% of dose as a bolus over 1 min.
admit to critical care
perform neuro assessment and VS every 10-15 mins during infusion and
every 30 mins after for at least 6 hours, monitor hourly for 24 hours after- be
consistent with BP device
if BP is over 180/105, administer anti-hypertensive
do not place invasive tubes
discontinue if pt reports severe headache, hypertension, bleeding, N/V
obtain follow-up CT, before anticoag/platelet drugs
-ataxia - -lack of muscle control or coordination of voluntary movements,
such as walking or picking up objects
-broca's area: - -in the frontal lobe
expressive (broca's or motor) aphasia: motor/speech problem, can
understand, cannot express-has difficulty writing
-ischemic stroke - -caused by a blockage of a cerebral artery by either a
thrombus or emboli
-causes of a thrombotic ischemic stroke - -arthersclerosis
hypertension
-s/s of thrombotic ischemic stroke - -protein in CSF
slow onset
pt is awake
TIA
slight headache
speech deficits
visual problems
confusion
improvements over weeks-months
-causes of embolic stroke - -cardiac disease
-s/s of embolic stroke - -sudden onset
pt is awake
paralysis
expressive aphasia
rapid improvements
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