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 |