Final Exam NR 325 Study Guide

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Final Exam NR 325 Study Guide

Latest 2023 / 2024

• How does the nurse confirm a basal skull fracture when implementing evidence based

practice? What is the nurses’ responsibility in each of these diagnosis?

Types of skull fractures: linear or depressed, simple, comminuted or compound, open or closed.

**Basilar fracture is a a specialized linear fracture involving the base of the skull (breaking of bones at the base of the skull.) Manifestations appear over several hours which include: cranial nerve deficits, Battle’s Sign (postauricular ecchymosis), periorbital ecchymosis (raccoon eyes).Fracture associated with a tear in the dura and leakage of CSF. Rhinorrhea(CSF leakage for the nose) and otorrhea(CSF leakage from the ear), this confirms the fracture has extended into the dura. CSF leakage=high risk meningitis and antibiotics should be given as preventative. Other Manifestations:bulging tympanic membrane caused by blood or CSF, tinnitus/hearing difficulty, facial paralysis, conjugate deviation gaze (both eyes are deviated in the same direction) and vertigo.

TWO Diagnostic tests used to determine if CSF is leaking from nose or ear: if there is drainage. 1 st : Dextrostix/Tes-Tape stripis used to determine if glucose is present **Remember CSF is loaded with glucose**. (If blood present testing is unreliable because blood also contains 1 / 4

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glucose. **Look for Halo Sign or Ring Sign**= by allowing the leaking fluid to drip onto white gauze pad or towel and observe drainage. Within minutes, blood moves into the center and a yellowish ring will encircle the blood if CSF is present. Note color appearance and amount of leakage. False positive results could occur.

Major potential complications of skull fracture= intracranial infections, hematoma, meningeal and brain tissue damaged. Also note if basilar skull fracture is suspected NG tube or oral gastric tube should be inserted under fluoroscopy. (pg. 1369) Intracranial Pressure Manifestations: (ATI pg. 14)Monitor for these manifestations **listed in Question 21. **

• What is the emergency intervention for a conscious client who has a suspected cervical (spinal)

cord injury? Identify the differences between Cervical, Thoracic, and Lumbar cord injuries and their treatments associated with each injury. What is the nurses’ responsibility in each of these diagnosis?Acute care of suspected cervical (spinal) cord injury: Immobilize vertebral column, Maintence of heart rate (atropine), and BP (dopamine), Insert NG tube and attach suction. Intubation if needed. O2 administration by high humidity mask, indwelling catheter, administer IV fluids, stress ulcers prophylaxsis. DVT prevention, bowel/bladder training.

*C4 injury=Tetraplegia. Above C4 patient will have total loss of respiratory function (Mechanical ventilation required) Below C4 results in diaphramgtic breathing if phrenic nerve is functioning.Nursing intervention=Patient can not cough and remove secretions, pneumonia and atelectasis can develop. 2 / 4

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*C6 Injury= Partial paralysis of the hands and arms and lower body *T6 Injury=Paraplegia=Paralysis below the chest Any injury above T6, Patient will have bradycardia & periperihal vasodilation=hypotension.

*L1 Injury= Paralegia=Paralysis below the waist. Injury above L1/L2 will convert to spastic muscle tone after neuro shock (upper motor neuron injuries).Injury below L1/L2 convert to a flaccid type of paralysis (Lower motor neuron injuries)\

*Autonomic dysreflexia: ATI pg. 16

Nursing Interventions: encourage active ROM exercises if possible, passive if patient lacks motor functions. Monitor I/O, Maintain fluids to prevent urinary calculi and bladder infections. Prevent skin breakdown, can use special bed and equipment for this. Monitor bowel sounds (ileus could develop). Change position every 2 hours (can not feel pain or prolonged pressure). Teach about sexual functions. Quad patients/upper motor neuron=usually capable of reflexogenic erections (erections secondary to manual manipulation) Ejaculation coordination with emission might not occur. Lower neuron injuries less likely to have reflexogenic erections but might be able to have combo of reflexogenic and psychogenic erections (sexual thoughts/images).

Bowel: Use daily stool softeners or bulk-forming laxatives. Bowel movement can be stimulated daily or everyother day by bisacodyl suppository or digital(finger) stimulation. ** Use digital stimulation cautiously to avoid provoking a vagal response, which leads to bradycardia and syncope.

Questions 7 lists Bladder interventions.

Patient can experience two types of shock: spinal shock: decreased reflexes, loss of sensation and flaccid paralysis below the level of injury, can last days to month and may mask postinjury 3 / 4

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neurological function. Neurogenic shock: contrast to spinal shock due to the loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and decreased cardiac output. Usually associated with cervical or high thoracic injury.

**Nursing interventions for neurogenic shock: Monitor for hypotension, dependent edema, and loss of temperature regulation (common manifestations). When Patient is upright, patient will experience postural hypotension. When transferring a client to a wheelchair: slow and in stages

· Raise the head of the bed and be ready to lower the angle if patient gets dizzy. Transfer the client into a reclining wheelchair with back of the wheelchair reclined. Be ready to lock and lean the wheelchair back onto knee to a fully reclining position if the patient reports dizziness after transfer. Do not return patient to the bed · Monitor for manifestations of thrombophlebitis (swelling of extremity, absent/decreased pulses, and areas of warm and tenderness) Patient may need anticoagulants to prevent development of lower extremity thrombi.

• What are the signs of appendicitis, positive signs, the treatment, pharmacotherapy, and what

does a potential rupture, and rupture look like? What are the surgical interventions? What is the nurses’ responsibility in each of these diagnosis?Signs of appendicitis: Abdominal pain in the RLQ, rigid abdomen, decreased or absent bowel sounds, fever, diarrhea/constipation, lethargy, tachycardia, rapid shallow breathing, anorexia, possible vomiting.Positive signs: Abdominal pain that is most intense at McBurney’s point. Rebound tenderness and abdominal rigidity, elevated white blood cell count.

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