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JCCC NURS 225 Unit 2: Questions & Answers (Correct)
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JCCC NURS 225 Unit 2: Questions & Answers (Correct)
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JCCC NURS 225 Unit 2: Questions & Answers (Correct)Primary headache Right Ans - a headache for which no specific organic
cause can be found
Secondary headache Right Ans - a symptom of a disease
Cluster headache Right Ans - Unilateral, severe periorbital headache with
tearing and conjunctival erythema.
Tension headache Right Ans - -pain is like a band squeezing the head
-worsens with activity
Nursing interventions for headaches Right Ans - -have client write down
triggers
-maintain cool, dark, quiet environment
-HOB 30 degrees
Head injury Right Ans - any trauma to the scalp, skull, or brain
TBI Right Ans - insult to the brain from an external mechanical force,
possibly leading to permanent or temporary impairment of cognitive,
physical, and psychosocial functions
Possible causes of head injury Right Ans - -Stroke and Hemorrhage
-Subdural Hematoma
-Infection
-Neoplasm
-Hypoglycemia
-Hypoxia
-Chemical toxins
-Changes in body temp
Head injury s/s Right Ans - -Amnesia
-Severe headache
-Deteriorating level of consciousness
-Dilated/pinpointed pupils (sluggish)
-Alteration in breathing pattern
-Deterioration in motor function
,-CSF leakage from ears/nose
-Seizures
What should you always suspect with a head injury? Right Ans - Cervical
spine injury
Decerebrate Right Ans - extension away from body, pronation of arms/legs
Decorticate Right Ans - Arms, wrists, fingers flexed....bent inward to chest
What is a normal adult ICP value? Right Ans - 5-15 mm Hg
Mannitol Right Ans - -osomotic diuretic of choice for increased ICP patients
Diabetes Insipidus (DI) Right Ans - -insufficient secretion of antidiuretic
hormone (ADH)
-large volume of dilute urine
SIADH Right Ans - -too much antidiuretic hormone (ADH)
-decreased urine output
Cushing's triad Right Ans - -Increased blood pressure
-Decreased respirations
-Decreased pulse
Subarachnoid Hemorrhage Right Ans - "Worst headache of my life"
What is the golden window to treat head injuries? Right Ans - 1 hour
Lumbar Puncture Right Ans - -Instruct the client to lie flat for 4-8 hours as
this decreases the risk of headache and leakage of CSF
Nursing interventions for increased ICP Right Ans - -Elevate HOB 30
degrees
-Dark/quiet environment
-stool softeners to prevent straining
-no caffeine
Risk factors for herniated disc Right Ans - -heavy lifting
, -male
-genetics
-heavy work
-weight
Herniated disk s/s Right Ans - -sudden pain that radiates down left leg
-groin/hip pain
-pain aggravated by activity & sitting
What is the primary treatment for herniated disks? Right Ans - Physical
therapy
Micro-discectomy Right Ans - surgical removal of part (or possibly all) of a
vertebral disc that has herniated
Spinal stenosis Right Ans - enlargement of facet joints/bone spurs in the
back of the vertebrae
Laminectomy Right Ans - Removal of lamina part of bone to either access
an area for disc fragment removal or decompress an area that is pushing on a
nerve root
What pre-op assessment needs to be done for spinal surgeries? Right Ans -
Neuro checks to compare to post-op
What post spinal surgery intervention should be done Q2? Right Ans - Log
rolling
Secondary effects of spinal cord injury Right Ans - -Breathing issues (C1-C4
damage)
-Bladder issues
-Bowel issues (above T12 is reflex bowel, below is flaccid bowel)
-Skin breakdown
-Temperature regulation issues
Spinal shock Right Ans - results in flaccid paralysis and absent reflexes
below the injury
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