Upgrade to remove ads
Theory Test 2: Focus 3 & 4
Terms in this set (96)
Mental processing and mental function characterized by knowing, thinking, learning, understanding and judging. Dependent on adequate perfusion, oxygenation and nutrients (carbohydrates)
Cognition: Population at risk?
All ages, but specifically older adults and adolescents
Risk factors for cognition impairment
-Past medical history
-Degenerative pathologic condition
A nurse is caring for a patient with ICP. Which action is considered unsafe?
Clustering many nursing activities
Which assessment finding would be the earliest and most sensitive indicator that there is an alteration in intracranial regulation?
Change in level of consciousness
The nurse should teach a patient that which is a primary prevention strategy to reduce the occurrence of head injuries?
Violence (trauma) prevention
Prodromal seizure phase
signs or activity that precedes a seizure such as agitation or restlessness
Aural seizure phase
a sensory warning such as light changes
Ictal seizure phase
Full seizure, patient not breathing
Postictal seizure phase
period of recovery
a state of constant seizure or condition when seizures recur in rapid succession without return to consciousness between seizures.
-Considered a neurologic emergency because it can result in brain damage or death
-limits on work or education
-Loss of consciousness
-Diaphoresis (excessive sweating)
-Continuous muscle contractions
-Extreme muscular rigidity
-Postictal: lethargy, altered LOC
Diagnostic testing for seizures
-EEG to pinpoint seizure focus
-Labs: CBC, CmP, UA to rule out metabolic disorders
-CT/MRI to rule out structural lesions
-Cerebral angiography to view vasculature
What drug is commonly given during status epilepticus?
What is the #1 concern with a seizure?
Acute interventions - when a seizure happens
-Ictal phase: note what preceded the seizure, how long did each phase last and what occurred during each phase
-Postictal phase: asses LOC, vital signs, pupil size, memory loss, muscles soreness, speech disorders, duration of symptoms. Be sure to maintain airway, provide suction, and O2 as needed
A nurse observes a patient ambulating in the hall when the patient's arms and legs suddenly jerk and the patient falls to the floor. Which will the nurse do first?
ASSESS the patient for a possible head injury
Priority with seizures is assessment first, then attempt to place patient on side to prevent aspiration. If assessment is not one of the choices, place to the side is a priority to prevent aspiration.
What items are considered seizure precautions?
-Acute inflammation of the meningeal tissue which surrounds the brain and spinal cord
-Often secondary to viral respiratory disease
-If left untreated it is near 100% fatality
-Inflammatory response causes ICP
Risk factors of Meningitis
-Season - fall, winter, and early spring
-College students in dorms - close living quarters
Meningitis assessment findings
-Nuchal rigidity (neck stiffness)
-Photophobia (eye discomfort when light is present)
-Seizures with increased ICP
Consequences of meningitis
-AMS (aseptic meningitis syndrome)
-Dysfunction of cranial nerves
-Headaches that may last months after diagnosis
Meningitis Diagnostic Testing
-Lumbar puncture to identify organism
If someone has meningitis, when is antibiotic therapy started?
Antibiotic therapy is started after a sample of CSF has been collected and before diagnosis is confirmed. This is so that the antibiotic therapy does not interfere with the contents of the CSF and alter test results.
Which drug is used to treat brain swelling/edema?
Glucocorticoid - dexamethasone
Nursing interventions for meningitis
-Prevention through vaccination and early treatment of respiratory tract and ear infections
-Fevers should be treated aggressively because it can cause cerebral edema, increases metabolic rate and causes dehydration
-Meningitis usually requires respiratory isolation (combination of droplet and contact; surgical mask, gloves, goggles and gown)
-similar signs and symptoms to bacterial meningitis
-antibiotics started while waiting for CSF cultures
-Full recovery is expected
Chronic, progressive, degenerative disease of the brain (not a normal part of aging)
-Amyloid plaques in brain
-Loss of connection between neurons
Alzheimer's risk factors
Alzheimer's diagnostic testing
-No definitive test
-CT/MRI may show brain atrophy
-PET scan can be used to differentiate AD from other diseases
Alzheimer's nursing interventions
Eating and swallowing difficulties
-use pureed, thickened liquids, supplements
-calm, distraction free environment while eating
-speech therapy assessment
-UTI and pneumonia due to poor self cares and swallowing issues
-Incontinence, immobility, and undernutrition
-very stressful, emotional and physical health problems, conflict
referring to outside the cell
refers to sodium balance
What would an increased concentration of potassium stimulate the kidneys to do?
can be oral, IV, or via tube feeding
can be urine, stool, diaphoresis (sweating), burns, or would drainage
regulates renal excretion of sodium and water; also facilitates the excretion of potassium
regulates the excretion of water but NOT sodium
What is lost through diarrhea?
water and electrolytes such as potassium
Why do burns cause hyperkalemia?
Cells contain potassium and when the cell walls are damaged, potassium leaves the cell and moves into the extracellular fluid leading to hyperkalemia
Why are daily weights important?
rapid weight gain or loss can show fluid retention or fluid loss
Why are children at risk of improper fluid and electrolyte balance?
they are unable to communicate, have immature kidneys and less body surface area
Why are older adults at risk for improper fluid and electrolyte imbalance?
their bodies are less responsive to antidiuretic hormone (ADH), they have a sensation loss (don't feel thirsty), and they most likely have other health issues as well
What are the consequences of fluid and electrolyte imbalance in relation to tissue perfusion?
-During a deficit, extracellular volume reduces tissue perfusion but reducing BP
-During an excess, extracellular volume pushes cells farther from capillaries creating a longer distance for oxygen to travel in order to defuse
What will K+ and Ca+ imbalances lead to?
-Dysrhythmias causing impaired perfusion
-Impaired neuromuscular function causing weakness, twitching, and cramping
What will low sodium cause?
cerebral edema putting the patient at risk for a seizure
*sodium excess/deficits affect the brain
What will high sodium cause?
cell shrinkage in the brain putting the patient at risk for a seizure
*sodium excess/deficits affect the brain
What is important to know about corticosteroids?
they can cause water retention
What does furosemide (Lasix) do?
It is a loop diuretic that treats edema and fluid retention by preventing the body from absorbing too much sodium and excreting it through urine
-patients should be educated to drink plenty of fluids to prevent dehydration
-should also be educated to stand and change positions slowly to prevent orthostatic hypertension
What diagnostic tests are performed to determine fluid/electrolyte imbalance?
-CBC will show hemoglobin and hematocrit levels (during dehydration hemoglobin/hematocrit concentrations will be high)
-CMP will show creatine and BUN levels which will measure kidney function and electrolyte concentrations
-UA will show sodium concentration
What is the #1 concern for dehydrated patients?
Dehydration can cause severe dizziness
What is hypovolemia?
fluid volume deficit
Risk factors for hypovolemia?
-Diabetes insipidus and polyuria because large amounts of fluid is lost through urination
-Use of diuretics because they cause sodium and water excretion
-vomiting, NG suction, diarrhea
How does hypovolemia lead to an increased pulse?
Fluid loss causes BP to lower, body compensates for a low BP by increases pulse to maintain adequate tissue perfusion
What is hypervolemia?
fluid volume excess
Risk factors for hypervolemia
-excessive IV intake
Why would a patient with hypervolemia have a bounding pulse?
excess fluid causes the heart to work harder
What are some tell tail signs of hypervolemia?
-rapid weight gain
-distended neck veins
-dyspnea and lung crackles due to fluid accumulation in lungs
Why is skin assessment important for someone with hypervolemia?
-You can test the skin turgor and check for edema
-present edema leads to poor tissue perfusion which will cause skin breakdown
What is hypernatremia?
elevated serum sodium due to either water loss or sodium gain
Why is cerebral edema dangerous?
cerebral edema first causes changes in LOC and increased ICP which can lead to a coma
Risk factors for hypernatremia
-excessive sodium intake
-inadequate water intake
-excessive water loss
Signs of hypernatremia due to water loss
Signs of hypernatremia due to sodium gain
-increased BP (due to increased viscosity of blood?)
What is hyponatremia?
decreased sodium serum levels due to either loss of sodium containing fluids or due to excess water retention
Risk factors of hyponatremia
-Excess sodium loss
-Inadequate sodium intake
-Excessive water gain
Hyponatremia due to sodium loss
Hyponatremia due to water gain
-increased BP (due to excess blood fluid volume)
What are the first signs to show with sodium loss or gain?
neurologic signs will be first to show, such as change in LOC, dizziness or confusion
Why do renal and cardiac patients need to be aware of their intake?
renal and cardiac patients are more likely to retain fluids
Hypernatreamia vs Hyponatremia
Sodium and fluid have and inverse relationship
-Hypernatremia can result from fluid volume deficit (water loss)
-Hyponatremia can result from fluid volume excess
-Sodium imbalances have 'mostly' neurological complications
-Most serious complication is change in LOC and seizures
What is hyperkalemia?
High serum potassium due to:
-excess intake of potassium or
-impaired renal secretion
-shift of potassium from intracellular fluid to extracellular fluid (i.e burn patients)
Hyperkalemia affects what?
-Affects nerves and muscles, specifically heart and causes muscular weakness
-cardiac and renal patients need to monitored closely when receiving K+
Risk factors of hyperkalemia
-potassium salt substitutes
Why is cardiac health a priority which hyperkalemia?
hyperkalemia can cause life threatening dysrhythmias
How does Lasix work to treat hyperkalemia?
allows for potassium to be excreted through urine
How does kayexalate work to treat hyperkalemia?
allows for potassium to be excreted through feces
What is hypokalemia?
low serum potassium due to loss of potassium
Hypokalemia risk factors
-GI loss - diarrhea, vomiting or NG suction
-Use of diuretics
Which are the most serious assessment findings of hypokalemia?
-irregular pulse and
What is important to remember when administering potassium replacements?
-administer at the correct rate
-infiltration of potassium could lead to tissue necrosis
-giving Digoxin to a patient with low potassium will cause dig toxicity!!
Hyperkalemia vs Hypokalemia
-potassium imbalances have 'mostly' cardia compilations
-most serious complication is cardiac complications
-potassium imbalances also affect skeletal system
What is furosemide (Lasix)?
-prevent reabsorption of Na+ and chloride
-increases renal excretion of water, sodium, potassium and calcium
-Adverse effects include hypokalemia, dehydration, hyponatremia
Why is it important to monitor BP and pulse before giving furosemide (Lasix)?
if a patient has a low BP or pulse, administering Lasix with cause further fluid loss and decrease BP even more
What is hypercalcemia?
high serum calcium
What does hypercalcemia lead to?
REDUCED excitability of both muscle and nerve cells
Risk factors of hypercalcemia
-calcium containing antacids overdose!
-vit D overdose
-Certain cancers and malignancies
Nursing interventions for hypercalcemia
-mobilization and weight bearing exercises
-hydrate to help remove excess calcium
What is hypocalcemia?
low serum calcium
What does hypocalcemia lead to?
INCREASED excitability of muscle and nerve cells
Risk factors for hypocalcemia
-chronic kidney disease
-use of loop diuretics - furosemide (Lasix) which remember causes K+, Na+, Ca+ and water loss
Hypocalcemia assessment findings
-muscle twitching and cramping
-Chvostek's sign- facial nerve tapping causes twitch of nose or lip indication never hyper-excitability
-Trousseau's- BP cuff placed on upper arm and inflated causes twitching/contraction of hand and wrist
Hypercalcemia vs Hypocalcemia
-Calcium imbalances have 'mostly' muscular complications
-most serious complication is tetany and laryngeal spasms
-Hypo = increased muscle/nerve excitability
-Hyper = decreased muscle/nerve excitability
YOU MIGHT ALSO LIKE...
NSG 371 Test 1 - 9/11
nu 102 Fluid and Electrolytes
Med Surg 1 Focus 4
Fluid and Electrolytes
OTHER SETS BY THIS CREATOR
pain & inflammation
infection pharm 4
OTHER QUIZLET SETS
Seizures and Epilepsy
Surgery - OnlineMedEd
Medical-Surgical Test #3