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ATI-MedSurge-NeurMus
ATI-MedSurge-NEUROMUSCULAR
| Question | Answer |
|---|---|
| phenytoin (Dilantin), should be administered? | should be taken at the same time everday to maintain therapeutic levels |
| If a rash develops while taking phenytoin (Dilantin), pt. should? | report to HCP |
| Phantom limb pain should be treated as ________ | real pain |
| Neurontin (Gabapentin) is used for? | Tx of neuropathic pain |
| Post-OP amputation, pt. reports pain in residual limp, nursing priority? | treat the pain |
| Labyrinthitis and Ménière’s disease are... | inner ear problems |
| Labyrinthitis is? | an infection of the labyrinth, secondary to otitis media |
| Ménière’s disease is? | is a vestibular disease with a triad of symptoms – tinnitus, unilateral sensorineural hearing loss, and vertigo |
| Ménière’s disease, pt. teaching? | - move head slowly to decrease vertigo |
| Intracranial pressure S/S? | - restlessness - the Cushing Reflex (HTN/ widened pulse) - |
| Positive Romberg sign | It indicates that the patient is excessively reliant on his vision to maintain balance. The problem may lie in the vestibular or proprioceptive systems |
| Positive Babinski’s sign | No Response: Indicates damage to the peripheral nervous system, muscles, or tendons within the region. Flexion: the toes all curve inwards. This is the normal response with functional CNS |
| To determine pt. pain severity, nurse should use? | Pt. report of pain on a standardized pain scale |
| Rheumatoid arthritis usually occurs? (bilaterally / unilaterally) | bilaterally & symmetrically |
| Osteoarthritis usually occurs? (bilaterally / unilaterally) | unilaterally |
| Deviation of Rheumatoid arthritis is usually seen in? | small joints |
| alendronate (Fosamax) is prescribed for? | osterporosis |
| When should alendronate (Fosamax) be administered? | before breakfast, pt. should sit upright for 30 min. after administration |
| If pt. in is in a balances suspension skeletal traction experiences muscle contractions, what is a nursing priority? | check position and weight of ropes |
| Osteoarthritis, S/S? | crepitus, decreased ROM, involvement of larger joints, joint pain that resolves w/rest |
| Knee and hip arthroplasty is used to treat? | osteoarthritis, rheumatoid arthritis |
| Total hip arthroplasty, dislocation precautions? | use: elevated toilet set, straight chairs w/arms, abduction pillow bet. pt.legs while in bed -externally rotate the client’s toes -don't cross less -don't flex hips >90 deg. |
| Casts can be slit on one side (____) or both Sides (____) | univalved / bivalved |
| If compartment syndrome is suspected, priority nursing action? | Report finding to HCP |
| Open-angle glaucoma, is? | the aqueous humor outflow is decreased due to blockages in the eye’s drainage system (most common type) |
| Angle-closure glaucoma, is? | the angle between the iris and the sclera suddenly closes causing a increase in IOP |
| In emergency care of angle-closure glaucoma, nurse should anticipate to administer? | IV osmotic diuretics (rapidly reduce IOP) |
| Pupillary (constriction / dilation) is the effect to facilitate the flow of aqueous humor | constriction |
| Mydriatic ophthalmic drops cause pupillary(constriction / dilation)? | dilation |
| IV Epinephrine cause pupillary (constriction / dilation)? | dilation |
| Micturition reflex is the? | relaxation of the urethral sphincter in response to increased pressure in the bladder |
| Micturition reflex, can be stimulated by | pulling on pubic hair, stroking the inner thigh |
| Credé’s maneuver is done to? | downward pressure on the bladder to manually express the urine |
| Valsalva maneuver is performed by? | attempting to forcibly exhale while keeping the mouth and nose closed |
| Valsalva maneuver is done to? | evaluate the condition of the heart |
| Post-OP craniotomy nursing action? | elevate head of bed 30 deg, to reduce risk of intracranial pressure |
| Pts. with retinal detachment, usually report? | flashes of bright light or dark floating spots |
| The onset of retinal detachment is? | abrupt, vision loss without pain |
| A Basilar skull fracture involves? | a portion of the skull extending into the brain cavity |
| A Basilar skull fracture, can result in? | cerebrospinal fluid leakage, report to HCP |
| Glasgow Coma Scale, <8 | associated with severe head injury and coma |
| Glasgow Coma Scale, 9 - 12 | indicates a moderate head injury |
| Glasgow Coma Scale, >13 | reflects minor head trauma |
| Cheyne-Stokes respirations | breathing hyperventilation followed by apnea |
| CPAP | Continuous positive airway pressure |
| BiPAP | Bilevel positive airway pressure |
| PaCO2 of pt. on mechanical ventilator should be maintained at? | @ 35mm Hg |
| Respiration of pt. on mechanical ventilator should be checked every? | 1 to 2 hrs. |
| 3 types of ventilator alarms are ____, ____, and ____. | volume, pressure, apnea |
| Amyotrophic lateral sclerosis, is also know as ____ ____ ____. | Lou Gehrig's disease |
| Amyotrophic lateral sclerosis (ALS) is? | a disease of the nerve cells in the brain and spinal cord that control voluntary muscle movement |
| The greatest risk to ALS pt. is? | respiratory compromise due to paralysis of respiratory muscles |
| Death due to ALS usually occurs within? | 3 to 5 years of diagnosis |
| Hemianopsia is? | a condition in which a person can see only to one side, the left or right |
| When feeding pt. w/hemianopsia, nurse should encourage pt. to? | move visual field (head) to see full plate |
| Prior to feeding pt. w/CVA, nurse should assess? | swallowing and gag reflexes |
| Food should be placed where in mouth of pt. w/CVA | in the back of the mouth on the unaffected side. |
| Pt. w/CVA should be positioned how when eating? | upright position and swallow with the head and neck flexed slightly forward |
| Tensilon (Edrophonium chloride) test is? | an injection of edrophonium chloride used to diagnosis Myasthenia Gravis |
| Plasmapheresis is? | a blood purification procedure used to treat several autoimmune diseases |
| Myasthenic Crisis, S/S | respiratory muscle weakness, Myasthenic symptoms, hypertension, temporary relief w/Tensilon |
| Myasthenic symptoms include? | weakness, incontinence, fatigue |
| Cholingeric Crisis, S/S | muscle twitching, Cholinergic symptoms, hypotension, no relief w/Tensilon, relief w/Atropine |
| Cholinergic symptoms include? | Hypersecretions (nausea, diarrhea, respiratory secretions) and hypermotility (abdominal cramps) |
| A lumbar puncture is also known as a ____ ____. | spinal tap |
| Post-OP lumbar puncture pt. should | lie flat for 4 to 8 hrs. |
| An Embolic CVA is an? | ischemic types of stokes are caused by a thrombus or embolus |
| For an emergency Embolic CVA, nurse should anticipate administering? | Tissue plasminogen activator (Alteplase) |
| Recombinant Factor VIII, is administered in pt. with? | hemophilia |
| Nitro-Bid-IV (Nitroglycerin), is administered in pt. with? | angina |
| Lidocaine is administered in pt. with? | ventricular dysrhythmias |
| Sinemet should be administered with (high / low) protein foods? | Low, high-protein foods reduce absorption |
| Sinemet S/E | orthostatic HTN, dark urine, takes weeks for Therapeutic Effects |
| Guillain-Barre syndrome, greatest risk is? | Respiratory failure |
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