NUR 2214 Exam 3
- Body systems involved in has exchange
Answer
neurologic respiratory
cardiovascular
- labs indicative of impaired gas exchange
Answer
ABG CBC
Sputum Exam Skin tests Pathologic analysis
- S/S of adequate ventilation
Answer
breathing is quiet and effortless sat 95-100
skin, nail beds, lips are appropriate color thorax is symmetric with equal thoracic expansion bilaterally spinous processes are in alignment;scapulae are bilaterally symmetric AP is less than transverse trachea is midline breath sounds are clear
- NI for increased ICP
Answer
elevate HOB to 30 degrees distribute care 1 / 3
only suction when needed hyperventilation (decreases perfusion, only short-term intervention) bowel management ( stool softeners, laxatives)
- assessment of increased ICP
Answer
sustained or equal to 20 s/s
headache decreased LOC N/V CN 6 palsies (inability to turn the eye laterally outward) papilledema periorbital bruising
late sign cushings triad hypertension, bradycardia, irregular breathing
- Fibrinolytic therapy indications
Answer
after an acute ischemic stroke
4.5 hours after unless
Answer 2 / 3
older than 80 anticoagulation less than or equal to 1.7 NIHSS > 25 Hx of diabetes and stroke
- how to give fibrinolytic therapy
Answer
dosage based on weight perform double check of glucose
programmable pump, initial dose is 0.9mg/kg (max dose of 90mg) ocer 60 mins with 10% of dose as a bolus over 1 min.admit to critical care perform neuro assessment and VS every 10-15 mins during infusion and every 30 mins after for at least 6 hours, monitor hourly for 24 hours after- be consistent with BP device if BP is over 180/105, administer anti-hypertensive do not place invasive tubes discontinue if pt reports severe headache, hypertension, bleeding, N/V obtain follow-up CT, before anticoag/platelet drugs
- ataxia
Answer
lack of muscle control or coordination of voluntary movements, such as walking or picking up objects
- broca's area
Answer
in the frontal lobe
expressive (broca's or motor) aphasia
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