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NR 325 Exam 2 Comprehensive

HEAL100 Health Care — exam and revision material · Other

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Health Care exam material, 9 pages. Originally published on StudyMerit.

Pages
9
Academic year
2025/2026
Language
English

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Exam 2 Review Week 4 GLASGOW COMA SCALE -Scored by : eye-opening response, Best verbal response, Best Motor Response ● Lowest score is 3 (being the worst response) ● Best score is 15 (being the best neuro response) IMPAIRED COGNITION -Nursing Actions for agitated and confused clients ● Talk to the clients family and provide reassurance ● Request family to remain at bedside if possible ● Use calendars and list of scheduled activity to reorient the client ALZHEIMER’S -Early Stage ● Teach client to use memory and such as calendars ● Teach caregivers methods to prevent injury at home ● Encourage the client to set up advanced directives for future care -Late Stage ● Client will need total care ● Low stimulation environment ● Use distraction techniques for agitation HUNTINGTONS ● HIGH -calorie diet ( due to to constant movements aka Chiroform movement/ Chorea) PARKINSON’S ● Medication therapy is working if fine motor skills improve ( ex: tying shoelaces) ● Benztropine adverse effect: URINARY RETENTION ● PRIORITY: assist client with ambulation to prevent falls and injuries MULTIPLE SCLEROSIS -Triggers of exacerbation: ● Infection ( MOST COMMON) ● Viruses Downloaded by Studymerit Dotcom (samuelkaruiki40@gmail.com) lOMoARcPSD|6879242

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● Stress SPINAL CORD INJURY ● Monitor for increased Intracranial Pressure and seizures ● A client suffering from this disorder will need to have the HOB elevated 45 to 90 degrees AUTONONMIC DYSREFLEXIA ( t-6 or higher) -Signs and Symptoms ● Facial Flushing ● Sweating ● Elevated BP ● Decreased HR ICP ● Clear drainage from the nose and ears following a skull fracture (CSF) - Nurse SHOULD IMPLEMENT: ● Elevated HOB ● Continuous Pulse OX ● Quiet calms environment ● Fall and Seizure precautions ● Educated client and family CUSHING TRIAD EMERGENT SIGNS AND SYMPTOMS ● Elevated BP (systolic) ● Decreased HR ● Irregular respirations ( Cheyenne Stokes) ● THIS IS KNOWN AS CUSHINGS TRIAD HEMORRHAGIC STROKE - Anticipated provider orders for this disease process ● Peripheral IV access ● IV LABETOLOL if BP is elevated ● Informed consent for surgery ISCHEMIC STROKE *** TIME SENSITIVE TREATMENT*** -Facilitating communication ● Turn off TV Downloaded by Studymerit Dotcom (samuelkaruiki40@gmail.com) lOMoARcPSD|6879242

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● Reduce environmental stimuli ● Do not pretend to understand the client ● Use visual aids and gestures ● Allow extra time for the client to respond ● Ask simple yes or no questions ● Speak with normal volume and tone SEIZURES PRIORITY : TURN CLIENT ON SIDE AND PROTECT HEAD & NECK ● Ensure oxygen and suction are at bedside -NURSE SHOULD: ● Pad the sides of the bed ● Monitor GCS trends ● Administer pain meds ● Educate family about decreasing stimuli -Restraints are NOT to be used for this client -Educate patient NOT to double dose medication if a dose was missed WEEK 5 Pancreatitis LUQ radiates to back ● Patient should be NPO and receive IV fluids - PRIORITY nursing action ● Keep client NPO ● Administer IV fluids bolus - PRIORITY parameters to monitor ● BP ● Pain level -Capillary RF 5 seconds or greater indicates POOR perfusion in this client and should be addressed immediately = Pancreatic Necrosis Elevated clotting time Complication of pancreatitis is peritonitis Cirrhosis ● No alcohol intake ● Lactulose is given to reduce toxins in the body (ammonia) ● Avoid aspirin in these patients ● HIGH fiber diet and AVOID red meat LATE STAGES Downloaded by Studymerit Dotcom (samuelkaruiki40@gmail.com) lOMoARcPSD|6879242

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