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AH2 Final
Study Guide
| Question | Answer |
|---|---|
| Cause of acidosis | anerobic metabolism |
| Shock and oliguria | Caused by Aldosterone; blood shunts away from kidneys |
| Worsening shock | kidneys fail, urine output decreases, systolic falls below 60 |
| Labs and shock | liver failure |
| Clotting factors and shock | DIC |
| Define shock | inadequate tissue perfusion |
| S/S of anaphylactic shock | urticaria, respiratory distress, ABG's, wheezing |
| Medications and shock | use Dopamine do not use morphine |
| Bleeding from surgical site | apply pressure and elevate |
| Hemorrhage and fluids | Normal saline |
| S/S of shock | Start out normal BP with tachycardia |
| Types of Shock | anaphylactic, cardiogenic, obstructive, distributive |
| Cardiogenic | heart pump failure |
| Obstructive | outside the heart blockage of blood flow |
| Distributive | excessive dilation of blood vessels |
| Nursing Diagnosis and shock | Ineffective Tissue Perfusion |
| Treatment for Burns | Silver Sulfadiazine |
| Induce vomiting | Do not use syrup of Ipecac, esophageal burns |
| Snake bite venom | Wash with soap and water/keep patient calm |
| S/S of smallpox | Shows on face and forearms |
| Nursing diagnosis for mania | risk for injury |
| Medications for psychiatric emergency | haloperidol (Haldol) |
| Treatment for near drowning | Ventilation |
| Heat Exhaustion | skin is cold, clammy reports dizziness, weakness, hypotension, faintness treat with oral fluids |
| Abdominal injury | tenderness, distention, rigidity indicates abdominal bleeding and possibility of hypovolemia |
| Teaching for pacemaker | monitor radial pulse for 1 min, irregular heart rate/ rhythm that is lower than pacemakers set rate can indicate malfunction also grounded appliances are safe; no MRI’s |
| Care for a patient in V-fibrilliation | immediate defibrilliation, also patient will have absent peripheral pulses |
| MRI and pacemaker | contraindicated |
| F waves | very rapid P wavers appear as A-flutter |
| V-tach and dysrhythmias | rhythm regular, heart rate 150-250 can lead to irregular rythm V-Fib |
| Treatment for sinus tachycardia | decrease workload on the heart and treat cause |
| Location of sinus node | Right atrium |
| PVC's and symptoms | Dizziness, fatigue, lightheadedness |
| PAC and location in heart | Atria |
| Depressed ST segment | Ischemia |
| Brain voluntary movement, regulates heart rate | Frontal lobes for voluntary movement and medulla for heart rate |
| Define neurotransmitter and parts of a neurons | carries impulses over the synapse, Dendrite carries impules toward and Axon impulses away |
| Define Visceral sensory neurons | transmits sensory or motor impulses from ANS and PNS to the CNS |
| Myelin Sheath | electrically insulates neurons |
| Ascending tracks | white matter/sensory impulses |
| Neuro Assessment | Glasgow Coma scale |
| Cranial Nerves | Oculomotor, III; Hypoglossal, tongue; Olfactory, sense of smell |
| Acetycholine and response | stimulates muscle contraction |
| GCS score | 15 is good, 7 indicates comatose Deterioration in pts condition, Notify PHCP stat |
| EEG and teaching | Before the test make sure pts hair is clean and dry |
| Care for lumbar puncture | bed flat for 6 to 8 hours, monitor puncture site, encourage fluids |
| MRI teaching | assess no pacemaker, metal, tattoos, jewelry |
| Positive Babinski | stroking the sole of the foot results in extension of great toe and fanning out of remaining toes |
| S/S of ICP | headache, N, V, amnesia, drowsiness |
| Vitals & ICP | Late indication characterized by bradycardia, irregular respirations, & arterial hypertension (widening pulse pressure) |
| Assess of headache pain | keep diary, Aviod opioids |
| Treatment for tension headache | relaxation techniques; massage; dark, quiet room. |
| Seizure care | Prevent injury and maintain airway; put up the side rails and put pt on their side |
| Medications and seizures | anticonvulsant phenytoin (Dilantin) most common; noncompliance can lead to status epilepticus |
| Diabetes Insipidus and brain injury | Resulting in polyuria and polydipsa |
| Mannitol Assessment | utilizes osmosis to pull fluid into the intravascular space and eliminate it via the renal system so you will have increased urination; monitor serum osmolarity and electrolytes |
| Concussion | Cerebral concussion is considered a mild brain injury, characterized by headache, dizziness, or nausea and vomiting |
| Decadron and headache | lessen the edema/swelling and reduce symptoms |
| S/S spinal shock | immediately following injury, cord below injury stops functioning resulting in vasodialation, hypotension, and bradycardia; pt is unable to maintain temp (hypothermia) and reflexes below level of injury are lost causing retention of urine and feces |
| Teaching and Sinemet | converts into dopamine in the brain; used to treat Parkinson’s disease; eat for shortly after (not with or before); may discolor urine and sweat |
| Teaching confusion | calendars, clocks, personal items, seasonal decorations in pt’s environment; don’t correct them if delusional, instead focus on feelings; reduce stressors such as fatigue, overstimulation, pain; maintain usual routines |
| Treatment after craniotomy | ICU; frequent neurologic assessments every hour for the first 24 hours; CT scan to assess edema; assess pt response to change in body image |
| Define TIA | temporary blockage of blood to the brain |
| Rehab and stroke patient | Rehab right away to help keep current functioning |
| Patho of multiple sclerosis | degeneration of myelin sheath, inflamed nerves cause nerve impulses to slow down or become blocked |
| Teaching and Myasthenia gravis | energy conservation, schedule activities when meds are at peak level, proper nutrition, s/s of crisis conditions, rest periods, avoid people with infections and exposure to cold |
| S/S of Guillain-Barre | Ascending paralysis; plateau; descending resolution; pain, cramping or numbness |
| labs and Guillain Barre | lumbar puncture with CSF analysis shows normal cell count with elevated protein, pulmonary function test |
| Treatment for trigeminal neuralgia | dilantin, nerontin, and tegretol for nerve pain; baclofen and clonazepam may also be effective in controlling symptoms; alcohol injection; nerve block, surgery, radio-frequency ablation, or gamma knife radiosurgery |
| Bells palsy Treatment | prevention of complications is goal,prednisone for 7-10 days to decrease inflammation, analgesics for pain, antiviral, moist heat & gentle massage, facial sling |
| Eye care for bells palsy | to protect the eye: administer eye drops or eye ointment; teach patient to use a patch over the affected eye; advise patient to wear glasses or goggles especially when outside or in areas with particles in the air |
| Thymectomy and what disorder | used to treat MG; decreases production of Ach receptor antibodies which decreases symptoms in most patients |
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laotracuata
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