HESI

• how do you check for traumatic brain injury?

  check for ecchymosis behind the ears, fluid leaking from the ears, tinnitus or hearing difficulty, and periorbital ecchymosis around the eyes
• how do you determine if drainage is cerebral spinal fluid?

  observe for a halo around a spot of drainage
• what medication would you give a person who is complaining about w headache but is also at risk for traumatic brain injury?

  Acetaminophen because it does not cause CNS depression
• what does a lower score on the glasgow coma scale indicate?

  worsening neurologic condition
• what anticonvulsant medication should not be mixed with other medications?

  phenytoin
• how should mannitol be administered to a patient with intracranial pressure?

  through an IV undiluted since it is hypertonic and used to reduce intracranial pressure
• what side effects can result from administering furosemide?

  dehydration, potassium sodium and chloride loss, thrombosis and ototoxicity
• what type of diuretic is furosemide?

  a loop diuretic
• what is a side effect specific to loop diuretics?

  ototoxicity
• what are the signs and symptoms of meningitis?

  Fever and chills, headache, neck stiffness, irritability, and photophobia
• what is an important nursing diagnosis associated with meningitis?

  mobility impairment
• what does the recovery process look like for patients who underwent a traumatic brain injury?

  they may never be back to their former self
• what is the most important information to obtain prior to administering a radioactive iodine uptake test?

  use of OTC medications and vitamins, reactions to be stings or shellfish
• if a patient is presenting signs of hypothyroidism what labs would be drawn?

  CBC, TSH and free T4, blood chemistries
• what labs should be monitored after a patient is diagnosed with hypothyroidism?

  triglycerides and cholesterol levels because they can lead to coronary atherosclerosis
• how should you administer levothyroxine?

  in the morning on an empty stomach.
• what may interfere with the absorption of levothyroxine?

  calcium. it should be administer at least 4 hours AFTER the levothyroxine dose
• what are the priority actions for a patient with myxedema crisis?

  assess cardiac system, cover with blankets due to hypothermia and start sodium chloride iv to prevent circulatory collapse due to hypovolemia
• what signs can indicate a stroek may have occured?

  a carotid bruit, elevated BP, hyporeflexic deep tendon reflexes, weakness, slurred speak
• what symptoms indicate right sided stroke?

  Left-sided weakness, spatial perceptual deficits, visual deficits on the left side, increased distractability
• what interventions are important for patients with a diagnosis of stroke?

  monitor PTT daily, assess neurological status every hour, keep HOB elevated, monitor glucose levels daily
• when is thrombotic therapy contraindicated?

  when symptom onset is longer than 3 hours prior to admission
• what is homonymous hemianopsia?

  loss of visual field in the same half in both eyes
• when is a surgery for prevention of stroke indicated?

  in patients with small strokes symptoms of transient ischemic attack or mild stroke due to carotid artery stenosis
• what interventions do you implement to prevent joint deformities with one sided weakness?

  place the patient in prone position for at least 15 minutes 4 times a day, place the elbow higher than the shoulder and the wrist higher than the elbow on affected side, apply splints to arms and legs at night
• how many ml in an oz?

  30
• what should you instruct the friends of a person with a possible spinal cord injury to do before emergency personnel arrives?

  place a blanket over the patient, don’t move the patient, make sure the area is safe
• how would you address a patient whose respiratory is compromised but has possible spinal and neck injuries?

  preform the jaw thrust technique
• what are normal hemoglobin levels?


  11-16
• what is autonomic dysreflexia?

  Autonomic dysreflexia is a potentially life-threatening medical emergency characterized by a sudden onset of excessively high blood pressure due to spinal cord injury
• what are the manifestations of autonomic dysreflexia?

  Hypertension, bradycardia, blurred vision with seeing spots, nasal congestion and severe headache, sweating in face neck and shoulders, goosebumps and feelings of fear and apprehension
• what are the priority interventions for a patient experiencing autonomic dysreflexia?

  notify doctor, place patient in safe position, check urinary catheter for kinks, monitor BP
• if a patient does not want to live due to paralysis what should you do?

  arrange a meeting with the patient, his family and the healthcare team to discuss the patients concerns