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MEDSURGE FINAL MOD 5 LINCOLN
Terms in this set (73)
How would you communicate with a person who is hearing impaired?
Bring voice down to a lower pitch and face the patient
Patient with seizure disorder reports sensing an aura. What is the patient experiencing?
Can be visual distortion, odor, or sound.
Traumatic head injury - what findings would you report?
Loss of consciousness.
Meningococcal (bacterial) meningitis expected findings?
Severe headache, high fever, stiff neck, petechiae, photophobia - put patient in private room that is dark and quiet.
Lumbar puncture meningitis clear vs. cloudy.
Cloudy spinal fluid - if the fluid is cloudy, they have a bacterial infection (bacterial meningitis or encephalitis).
Patient is diagnosed with myopia; how would you explain myopia to the patient?
Nearsightedness. When you have clear vision of images that are near but difficulty seeing images that are farther away.
Trigeminal neuralgia - where is the nerve located?
Nerve lies on the side of the face near the ear.
Client with Parkinson's disease asks, "why can't I control tremors?"
Decreased dopamine production, relative excess of Acetylcholine, and impairment of semiautomatic movements.
what would be included in teaching for patient having an EEG?
Encourage the patient to be sleep deprived - they should be awake the night before, so they are tired. Hair should be clean and dry. They can drive themselves home in the morning because it is a noninvasive procedure. After procedure wash hair
What is the structure - insulation around the nerve?
What kind of meds would you order for a patient in the hospital with TIA and has a history of A fib?
Warfarin, Aspirin, and/or Clopidogrel.
Patient having an MRI understands teaching when they say?
No pacemaker, no metal, no jewelry.
How would you explain TIA to a patient?
a. A TIA looks and feels like a stroke but leaves no permanent damage. Like a stroke, TIA occurs when a blockage in a blood vessel stops the flow of blood to part of the brain. Unlike a stroke, TIA symptoms do not persist and resolve within 24 hours - and often much faster.
Patient comes in with facial drooping and slurred speech what do you think is going on with patient and what other testing would you do? You suspect stroke, what else would you see?
Stroke. Thrombolytic therapy, airway management, controlled hypertension clot busters TPA (thrombolytic therapy). F.A.S.T: FACE, ARMS, SPEECH, TIME!
Interventions for patient with Trigeminal neuralgia. What diagnostic test is needed?
Anticonvulsants, nerve blocks, surgery to block pain signals, can inject Botox to help, give room temp foods, soft to chew, nutritional counseling.
b. Medications prescribed to lessen or block the pain signals sent to your brain. Carbamazepine (Tegretol) is the drug of choice for the initial treatment.
Medications contraindicated in acute angle glaucoma. What should you check first before giving meds?
Mydriatics - learning tip - constrict pupil - atropine, antihistamines, and Vistaril can cause blindness**
Myasthenia gravis may improve over a short period of time, what response to the test would the nurse expect to see?
Edrophonium (Tensilon) test.
b. If muscle strength improves dramatically (patient can suddenly open eyes wide) MG is diagnosed. Increase ptosis (sudden droopy eyelid) occurs if MG is present. After a brief rest, the eyelids can be opened without difficulty.
What is the cause of right sided weakness in a patient that comes in with suspected CVA?
Left side hemiparesis.
How do you do a Romberg test?
Balance test. The patient is asked to remove shoes and stand with feet together. The patient is asked to stand quietly with eyes open, and then with eyes closed. They are scored by counting the seconds they can stand with eyes closed without swaying/ losing balance. Test is positive when the patient sways and loses balance with eyes closed.
Symptoms of cataracts.
Blurred-hazy vision, halo around lights, Yellow, white, or gray discoloration of pupil, gradual loss of vision.
Patient had cataract surgery, what would the nurse report to HCP?
Sudden or worsening pain, watery or bloody discharge, sudden loss of vision. After surgery patient should not have a lot of pain, they will be achy and can be treated with Tylenol but should not be in severe pain.
Patient with Meniere's disease, how do you know patient needs more teaching?
Restrict salt** chose diet that has high salty foods.
Dehydration from fluid volume deficit expected findings.
Confusion, weakness, thirst, weight loss, decrease urine output, dry mucous membranes, sunken eyeballs, weak pulse, tachycardia, decreased skin turgor, decreased BP, postural hypotension.
Serum potassium levels indication.
Too low or too high can cause arrhythmia
Data collection on a patient with 3lb weight gain and noisy respirations. What order would you question?
NSAIDS and Corticosteroids
Risk factors for myasthenia gravis.
Progressive muscle weakness. Classic sign is muscle weakness during activity and improvement after rest. Muscles are strongest in the morning, drooping eyelids present, difficulty swallowing.
How would you describe diabetic retinopathy to a patient?
Vascular changes in retinal blood vessels. Micro aneurysms can form in back of eye on retinal capillary walls, if they break causes edema causing pressure on retina - see in elderly. Changes related to excess glucose - they need to control blood sugar.
Priority intervention for a patient diagnosed with Bell's Palsy.
Important to protect the eye on affected side because they can't close eye lid properly.
Priority intervention for 48-year-old patient with multiple sclerosis.
ABCs - muscle weakness - respiratory issues/ failure and pneumonia.
Caring for 4 patients. Which patient would you see first?
Always look for the most unstable patient.
Data collection on patient ear health, what kind of questions would you ask them?
a. Health When was your last hearing evaluation?
b. history - were they on -mycins or oto-toxic meds?
d. Have they had an issue before? Is it new?
Signs and symptoms of increased intercranial pressure that you would report?
Restlessness, irritability, decrease in level of consciousness, hyperventilation, pupil changes, and Cushing's response ( symptoms - hypertension, bradycardia, and abnormal respiratory patterns).
What test would you use as an initial screening tool to determine hearing loss?
Whisper test (least invasive first).
Discharge teaching for patient with fluid imbalance. What instruction would you take priority to give for patient going home.
Electrolyte imbalance may be corrected by diet changes. Eat diet rich in potassium (bananas, cantaloupe, oranges, spinach, broccoli, potatoes, cucumbers, peas) if you have low potassium levels, or restricting your water intake if you have a low blood sodium level. Monitor daily weights.
Signs and symptoms of dehydration in adult patients.
What term would you use to document a finding that a patient ear is draining
Patient teaching for antibiotic eye ointment.
Ointments can make vision blurry - pull lower eyelid down to create a pocket, squeeze a ribbon of ointment out and from inner to outer canthus. Do not touch eye with dropper.
How would you know if medication for Parkinson's disease has been effective? What medication is effective?
Helps with disabling tremors by slowing/ stopping them
What procedure would you use to drain fluid from the ear?
Myringotomy is a tiny incision in the eardrum (tympanic membrane). Put tubes in ear to help drain.
What labs to monitor for patient complaining of having diarrhea for 2 days?
Electrolytes. Potassium, Sodium, Calcium, Magnesium, Chloride.
Pathophysiology of multiple sclerosis.
Degeneration of myelin sheath. Inflamed nerves. Slowed or blocked nerve impulses.
What is the term for ringing of the ears?
Patient teaching for angiogram. Which statement made by the patient indicates they understand the teaching? How is the dye removed?
a. Preprocedural: informed consent, clear liquid diet, insert IV needle, check BUN & Cr levels, check PT & PTT, administer sedation as ordered.
b. Postprocedural: flat in bed for 6 to 8 hours, monitor VS, catheter insertion site, and encourage PO fluids.
c. "I will drink fluids to remove excess contrast dye."
Expected findings in patient with macular degeneration. What would the patient report? 1120
Loss of central vision.
What is an appropriate nursing action if patient falls asleep after a tonic- clonic seizure and meals are being delivered?
Let them sleep. Prodromal stage.
Time frame for administration of TPA.
3 to 4.5 hours.
Patient only ate food on left side of the tray. What should the nurse do?
Turn the plate 180 degrees and observe the patients response.
The nurse is concerned that a patient has a high volume of insensible water loss. What is the patient experiencing that is causing the nurse this concern?
Perspiration - sweating.
Patient having tonic clonic seizures - what action would you implement first?
Turn on side, cushion head, remove restrictive clothing around neck, time it, offer help after, monitor airway, suction.
What would you do if IV site becomes red?
Stop IV and remove it.
Expected finding in patient with retinal detachment. What would the patient report?
Retina separated from back of eye. Can be spontaneous - looks like curtain coming down. May see cobwebs. Happens with boxers (punched in the eye). Sudden change in vision, flashing lights, floaters, looking through a veil, curtain being lowered over vision, no pain.
Patient who had a stroke will experience nausea and vomiting, what is the priority nursing action? Least invasive à most invasive.
If the patient is vomiting put them on their side to prevent aspiration. They can aspirate if you sit them up.
Trigeminal neuralgia - what is most likely to trigger pain?
Intense pain on one side of face, forehead, nose, cheek, jaw. Triggered by touch, talking, other stimulation - if they are chewing on something that is hard to chew it may stimulate the nerve and cause pain.
How would you know a patient on a low sodium diet needs further teaching?
Choses diet that has high salty foods.
Most important data to collect for patient with myasthenia gravis.
Determine muscle strength, how much activity can they tolerate before weakness and fatigue occur
Patient with T4 spinal injury. Patient is restless and BP increased. What is going on with the patient?
Perform bladder scan - patient may have full bladder and not able to feel it. Impaired function for urinary and bowel movements. Most common issue is bladder distension - high BP and get agitated, headache. If full empty the bladder to stop these complications.
CT scan with contrast dye would you recommend for patient after scan is done?
Encourage fluids. Want to see how kidney function is - BUN & Cr because the dye needs to be flushed out of the body through the kidneys.
Expected finding in patient with glaucoma. What would you expect the patient to report?
Mild aching, headache, halos around lights, frequent visual changes.
Patient has Parkinson's disease and displays bradykinesia - what is the appropriate action performed by the nurse.
How would you properly administer ear drops in adult client?
Pull the pinna up and back.
Patient diagnosed with Alzheimer's disease, and they fall frequently - how would you keep the patient safe?
Keep them busy, room close to nurse station, floor clear, and take to bathroom frequently.
What is the cause of Guillain-Barre syndrome?
Ask before giving flu shot if ever had GB as you can get it again. Monitor airway because accessory muscles are affected.
Definition of TIA.
is a brief episode during which parts of the brain do not receive enough blood. Because the blood supply is restored quickly, brain tissue does not die as it does in a stroke. These attacks are often early warning signs of a stroke
SATA: Lumbar puncture post-op care.
Lay flat, bedrest for 6 to 8 hours, encourage PO fluids, monitor puncture site, monitor movement, sensation, and headache.
SATA: Nursing care for cerebral aneurysm.
Prevent increased intercranial pressure. Surgical clipping of aneurysm, reduce noise level in patients room and administer stool softener.
SATA: Nursing interventions for patient in clonic phase of tonic clonic phase.
Turn to side, move hard objects, loosen clothing, suction PRN, time seizure.
SATA: Nursing interventions for Bells Palsy.
First intervention after ruling out stroke is to protect the eyes because they do not close properly. Patch the eye and ointment.
SATA: Teaching a client that has MG how to recognize a cholinergic crisis.
a. Nausea, muscle weakness, headache, rapid heart rate.
SATA: What would you expect to see in patient having anaphylactic shock.
Hives, wheezing, rash, swelling.
SATA: What data would indicate patient is at risk for hypertension.
Obesity, family history, smoker, poor exercise habits.
SATA: Which patient should be monitored closely for dehydration.
Elderly and babies. Patient vomiting and diarrhea.
SATA: Risk factors for hearing loss.
Working in factory without protection of ears. Working in yard with no protection. Using loud equipment, guns, etc.
SATA: Cataract patient findings.
Difficulty reading, halos, seeing bright light, sensitivity to glare.
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