Podcast
Questions and Answers
Which of the following is the MOST critical initial nursing intervention when a patient experiences a seizure?
Which of the following is the MOST critical initial nursing intervention when a patient experiences a seizure?
- Immediately inserting an oral airway to prevent tongue obstruction.
- Administering rescue medications immediately.
- Restraining the patient to prevent uncontrolled movements.
- Ensuring a patent airway and protecting the patient from injury. (correct)
A patient with delirium is agitated and confused. The caregiver asks if the patient can have medication to help the patient go to sleep. What is the BEST response?
A patient with delirium is agitated and confused. The caregiver asks if the patient can have medication to help the patient go to sleep. What is the BEST response?
- "Yes, if the provider orders the medication to help the patient."
- "Antipsychotic use will change the duration of delirium or length of hospitalization."
- "Administering medications will help with agitation- risk for falls and injury."
- "Let's try non-pharmacological methods first, as some medications can worsen delirium." (correct)
A patient with Parkinson's disease presents with a stooped posture and a shuffling gait. As the disease progresses, which assessment finding would the nurse MOST likely observe?
A patient with Parkinson's disease presents with a stooped posture and a shuffling gait. As the disease progresses, which assessment finding would the nurse MOST likely observe?
- Decreased risk of falls due to enhanced postural reflexes.
- Increased weakness and loss of postural reflexes, increasing the risk of falls. (correct)
- Increased muscle strength and rapid reflexes.
- Improved coordination and balance.
The nurse is educating a caregiver of a client with Alzheimer's disease who will be living at home. Which of the following instructions is MOST important for the nurse to include?
The nurse is educating a caregiver of a client with Alzheimer's disease who will be living at home. Which of the following instructions is MOST important for the nurse to include?
A patient with a known seizure disorder is prescribed levetiracetam. The nurse reviews the patient's latest lab results and notes the levetiracetam level is 8 mcg/mL. What is the nurse's BEST action?
A patient with a known seizure disorder is prescribed levetiracetam. The nurse reviews the patient's latest lab results and notes the levetiracetam level is 8 mcg/mL. What is the nurse's BEST action?
A patient is diagnosed with dementia. Which characteristic differentiates dementia from normal age-related cognitive changes?
A patient is diagnosed with dementia. Which characteristic differentiates dementia from normal age-related cognitive changes?
Which intervention is MOST appropriate for the nurse to implement to support adequate nutritional intake in a client with Alzheimer's disease?
Which intervention is MOST appropriate for the nurse to implement to support adequate nutritional intake in a client with Alzheimer's disease?
The nurse is caring for a patient at risk for delirium. Which of the following is a known risk factor for delirium?
The nurse is caring for a patient at risk for delirium. Which of the following is a known risk factor for delirium?
A client with a seizure disorder is in the postictal phase. Which assessment finding would the nurse expect to observe?
A client with a seizure disorder is in the postictal phase. Which assessment finding would the nurse expect to observe?
A patient with Parkinson's disease is scheduled for discharge. Which teaching point is MOST important for the nurse to emphasize to the patient and their caregiver?
A patient with Parkinson's disease is scheduled for discharge. Which teaching point is MOST important for the nurse to emphasize to the patient and their caregiver?
Flashcards
What is Dementia?
What is Dementia?
A disorder characterized by a decline from a previous level of function in cognitive domains like memory and language.
Early Signs/Symptoms of Dementia
Early Signs/Symptoms of Dementia
Losing words, increased confusion at night, difficulties with common tasks, changes in mood, personality.
Nursing Interventions for Dementia
Nursing Interventions for Dementia
Safety measures to prevent elopement and ensure safe cooking, along with monitoring, optimal environment and meeting patient needs.
Delirium Signs/Symptoms
Delirium Signs/Symptoms
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Nursing Interventions for Delirium
Nursing Interventions for Delirium
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Diagnostic Testing for Seizures
Diagnostic Testing for Seizures
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4 Phases of Seizure
4 Phases of Seizure
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Initial interventions for seizures
Initial interventions for seizures
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Signs/Symptoms of Parkinson's
Signs/Symptoms of Parkinson's
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Parkinson's Nursing Interventions
Parkinson's Nursing Interventions
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Study Notes
Dementia
- Dementia is a disorder characterized by a decline from a previous functional level in one or more cognitive domains.
- Cognitive domains affected by dementia include: complex attention, executive function, language, learning, memory, perceptual-motor skills, and social cognition.
- Dementia is not a normal part of aging.
- Potential Risk factors: HTN, AIDS, multiple sclerosis, medications, metabolic diseases, head injuries, brain tumors, and CTE.
Assessment/Signs and Symptoms (Dementia)
- Early warning signs: losing words, increased confusion at night
- Difficulties with common tasks and poor judgment can also be early signs
- Changes in moods and personality, as well as loss of initiative are further signs
Nursing Interventions (Dementia)
- Safety measures to prevent elopement and unsafe cooking habits
- Continuous monitoring and determining precipitating factors
- Providing patient needs and promoting sleep in an optimal environment
- Planning for elimination, nutrition, hydration, and hygiene will support the patient
Caregiver Teaching (Dementia)
- Caregivers should use redirect and distract techniques rather than correcting patients
- Establish a routine, ensure safety, and label household items for clients living at home
- Encourage family and friends to visit with the client
- The caregiver needs education on patient care, monitoring of diet and fluid intake, communication, and long-term placement
- Encourage adequate nutritional intake in clients with Alzheimer's disease by staying with them and encouraging them to eat
Causes of Dementia
- Alzheimer's disease
- Vascular dementia
- Dementia with Lewy bodies
- Frontotemporal dementia
- Parkinson's dementia
- Mixed dementia
- Other causes
Delirium
- Delirium is a state of acute confusion characterized by disturbances in attention, awareness, and cognition
- Dementia and dehydration are the risks
Assessment/Signs and Symptoms (Delirium)
- The four hallmark features of delirium include: acute onset and fluctuating course, inattention, disorganized thinking, and altered level of consciousness.
Nursing Interventions (Delirium)
- During agitation, address the cause, ensure safety, educate the family, and provide care.
Seizures
- Seizures involve the abnormal discharge of neurons in the brain, leading to various manifestations.
Assessment/Signs and Symptoms (Seizures)
- Seizures have four phases: prodromal, aural, ictal, and postictal.
- Prodromal phase: Changes precede the seizure by hours or days.
- Aural phase: a warning sign that is usually part of the seizure, including incontinence, warm skin, and tachycardia.
- Ictal phase: active seizure phase from first symptoms to the end of the seizure period
- Postictal phase: post seizure period
Nursing Interventions (Seizures)
- Time the seizure activity and ensure that it is time-stamped
- Initial assessment: H&P, neurological assessment, and situation (triggers or aura and what happened)
- Education on medication adherence, triggers, labs, and psychosocial support is helpful
Assessment Findings (Seizures)
- Aural phase: Variable experiences
- Tonic phase: continuous muscle contractions
- Hypertonic phase: intense muscular rigidity lasting 5-15 seconds
- Clonic phase: rigidity and relaxation alternating in rapid succession
- Postictal phase: altered level of consciousness, confusion, headache
Interventions (Seizures)
- Ensure patent airway
- Protect from injury (do not restrain, pad side-rails, turn to side).
- Remove sharp objects/glasses and loosen tight clothing
- Establish IV access and anticipate rescue medications
- Assist with ventilations if the patient does not breathe after and anticipate the need for intubation; stay with the patient
- Monitor vital signs, level of consciousness, O2 saturation, GCS results, and pupillary response (PERRLA)
Causes (Seizures)
- Drug-related, head trauma, infection, intracranial events, medical/metabolic problems, or other
Parkinson's Disease
- Parkinson's is a degenerative neurological disorder
Assessment/Signs and Symptoms (Parkinson's)
- Tremor, rigidity, pill-rolling, bradykinesia, postural instability, shuffling gait, stooped posture, and orthostatic hypotension are all signs
Nursing Interventions (Parkinson's)
- Administer medications, fall risk precautions, promote independence
- Educate on therapeutic measures (OT, PT, ST), nutritional therapy, and support groups
- Neuro assessments and musculoskeletal: monitor for weakness and progression of tremors
- Education on therapy referral, medication education/adherence, adequate nutrition, mental health, and caregiver considerations.
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