NUR2755 / NUR 2755 Final Exam
: Multidimensional Care IV /
MDC 4 - Rasmussen
Alzheimer's Mild Stage Correct Answer: -Forgets names; misplaces
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-Has short-term memory loss and difficulty recalling new information
-Shows subtle changes in personality and behavior
Alzheimer's Moderate Stage Correct Answer: -Is disoriented to time, place, and event
-Has difficulty driving and gets lost
-Incontinent
-Psychotic behaviors, such as delusions, hallucinations, and paranoia
-Episodes of wandering, trouble sleeping
Alzheimer's Late Stage Correct Answer: -Totally incapacitated; bedridden
-Totally dependent in ADLs
-Has agnosia
-Hallucinations
-Incontinence
-Difficulty eating
Apraxia Correct Answer: Difficulty with motor planning to perform tasks or movements
Aphasia Correct Answer: Inability to speak or understand language
Anomia Correct Answer: Inability to recall the names of everyday objects
Agnosia Correct Answer: Loss of sensory comprehension, including facial recognition
Alzheimer's diagnostics Correct Answer: -No laboratory test can confirm the diagnosis of AD
-Definitive diagnosis is made on the basis of brain tissue examination at autopsy, which confirms the presence of neurofibrillary tangles and neuritic plaques
Alzheimer's medications Correct Answer: Cholinesterase inhibitors- Donepezil, galantamine
NMDA receptor antagonists- Memantine
Parkinson's symptoms Correct Answer: -Slow, shuffling, and propulsive gait
-RESTING tremors
-Muscle rigidity
-Bradykinesia/akinesia (loss of ability to move muscles voluntarily)
-Mask Like face
-Drooling
-Postural instability
Parkinson's diagnostics Correct Answer: -Diagnosis typically made based on manifestations, their progression, and by ruling out other disease
-Analysis of CSF may show a decrease in dopamine levels
Parkinson's medications Correct Answer: Carbidopa/Levodopa (Sinemet)
Parkinson's surgical interventions Correct Answer: Stereotactic pallidotomy or thalamotomy
Migraine triggers Correct Answer: -Caffeine
-Red wine
-MSG
-Foods high in tyramine (aged cheeses, cultured food like yogurt)
Migraine abortive therapy Correct Answer: Acetaminophen, ibuprofen, naproxen, triptans, ergotamine derivatives
Migraine preventative therapy Correct Answer: Beta blockers, calcium channel blockers, antiepileptics, Botox
Migraine surgical treatment Correct Answer: Trigeminal nerve resection
Aura symptoms Correct Answer: -Visual disturbances
-Flashing lights/lines/spots
-Numbness of lips or tongue
-Acute confused state
-Aphasia
-Vertigo
-Unilateral weakness*
-Offensive smell
-"Deja vu" feeling
Multiple sclerosis clinical manifestations Correct Answer: -Muscle weakness and spasticity
-Intention tremors (tremor when performing an activity)
-Diplopia (double vision)
-Nystagmus (an involuntary condition in which the eyes make repetitive uncontrolled movements)
-Depression/labile
Multiple sclerosis diagnosis Correct Answer: MRI of the brain and spinal cord demonstrates the presence of plaques in at least 2 areas
Multiple sclerosis medications Correct Answer: -Baclofen
-Disease-modifying therapies
-Interferon beta-1a and beta-1b
-Corticosteroids
Meningitis clinical manifestations Correct Answer: -Nuchal rigidity
-Kernig Sign
-Brudzinski Sign
-Decreased level of consciousness
-Photosensitivity
Kernig Sign Correct Answer: Resistance and pain with extension of the client's leg from a flexed position
Brudzinski Sign Correct Answer: Flexion of the knees and hips occurring with deliberate flexion of the client's neck
Meningitis diagnostics Correct Answer: Lumbar puncture
Appearance of CSF: cloudy (bacterial) or clear (viral)
Prevention of meningitis Correct Answer: Meningococcal vaccine
Droplet precautions Correct Answer: -Private room
-Stay at least 3 feet away from the patient unless wearing a mask
-Patients who are transported outside the room should wear a mask
-Health care personnel should wear gloves, gown, and mask
Tonic-clonic seizure Correct Answer: Generalized seizure in which the patient loses consciousness and has both stiffening of the muscles (tonic) and rhythmic jerking of the extremities (clonic)
Tonic seizure Correct Answer: Clients suddenly lose consciousness and experience sudden increased muscle tone, loss of consciousness, and have autonomic manifestations
Clonic seizure Correct Answer: Only the clonic phase is experienced (rhythmic jerking of the extremities)
Myoclonic seizure Correct Answer: Lasting only seconds, myoclonic seizures consist of brief jerking or stiffening of the extremities, which can be symmetrical or asymmetrical
Atonic or akinetic seizure Correct Answer: Characterized by a few seconds in which muscle tone is lost
Complex partial seizure Correct Answer: -Seizures associated with automatisms (behaviors that the client is unaware of, such as lip smacking or picking at clothes)
-Can cause loss of consciousness
Simple partial seizure Correct Answer: Seizure where consciousness is maintained
Seizure diagnostics Correct Answer: -Electroencephalogram (EEG)
-CT/MRI
Seizure interventions Correct Answer: -Turn the patient on their side
-Remove objects that may injure the patient
-Suction as needed
-Oxygen
-Padded side rails
-IV access (saline lock)
-Bed in lowest position
-Nothing in mouth
-Loosen or remove restrictive clothing
Seizure medications Correct Answer: -Lorazepam or diazepam IV push to stop a seizure (4 mg over a 2 minute period)
-Phenytoin (therapeutic range 10 to 20 mcg/ml)
Earliest sign of increased intracranial pressure Correct Answer: Decreased level of consciousness
Increased intracranial pressure early signs Correct Answer: -EARLIEST SIGN: Decreased level of consciousness
-Restlessness
-Changes in speech
-Confusion
-Headache
-Nausea and vomiting → projectile
Increased intracranial pressure late signs Correct Answer: -Pupillary changes → can mean herniation
-Cranial nerve dysfunction
-Ataxia
-Cushing's triad (very late sign)
Increased intracranial pressure interventions Correct Answer: -Low stimulation
-Semi-fowlers → 30 degrees
-Head in neutral position
-Do not cluster activities
-Suction only as needed
-Teach patient not to cough or blow their nose
-Dim lighting
-Stool softeners
-Do not bend or bare down
Increased intracranial pressure treatment Correct Answer: IV mannitol given through a filter because it crystallizes at room temperature
Cushing's triad Correct Answer: Severe hypertension, widened pulse pressure (difference between the systolic and diastolic blood pressure), bradycardia, irregular respirations
Pulse pressure Correct Answer: Difference between systolic and diastolic pressure
Ischemic stroke Correct Answer: Caused by the occlusion of a cerebral artery by either a thrombus or an embolus.
Thrombotic stroke Correct Answer: Occur secondary to the deve [Show Less]