NUR 265 EXAM 4 QUESTIONS AND
ANSWERS
/. Lupus: Hallmark sign - Answer-butterfly rash on face
/.Lupus: Indication of flare - Answer-Fever and fatigue
*also assess BUN function
*c reactive protein remains normal
/.Lupus: Interventions - Answer--Falls precautions
-treat pain with tylenol and NSAIDS (monitor kidney function)
-AVOID SUNLIGHT
-REPORT FLARE IMMEDIATELY
-clean skin with mild soap and pat dry and apply lotion
/.Lupus: medical management - Answer--hydroxychloroquine(anti-malarial) decreases
absorption of UV light
/.Scleroderma - Answer-inflammatory, autoimmune connective tissue disease
/.Scleroderma: Hallmark Sign - Answer-Hard, leather-like edematous skin
Late: esophageal dismotility
/.Scleroderma: Assess - Answer-Swallow safety--esophageal dysmotility (ASPIRATION)
O2
circulation
skin
/.Scleroderma: Interventions - Answer-aspiration precautions (keep HOB at 60 degrees
during meals and after)
skin protection measures
small frequent meals--avoid caffeine and alcohol
-avoid spices, caffeine and pepper
/.fibromyalgia: S/sx - Answer-extreme fatigure
GI symptoms
dysuria
blurred vision
forgetfulness
/.fibromyalgia: Assess - Answer-pain level
extreme fatigue
,GI symptoms
/.Fibromyalgia: Interventions - Answer-NSAIDS
Nuerontin (gabapentin)
Lyrica (pregabalin)
SNRI and tricyclic antidepressants (amitriptyline)
promote sleep and low impact exercise (stretching, walking, swimming, rowing, water
exercise)
/.Lyme Disease: Hallmark sign - Answer-stage 1: "bulls eye rash" and flu-like symptoms
Stage 2: facial paralysis, carditis, meningitis
/.Lyme Disease: Assess - Answer-Skin
history of tick bites
/.Lyme Disease: Interventions - Answer-prevention!
Insect repellant with DEET
early stage--doxycycline antibiotics ORAL
late stage--Iv antibiotics (ceftriaxone)
avoid tall grass
wear light colored clothing
have pets wear tick collars
/.Allergic Reaction Priority - Answer-STOP THE INFUSION/ELIMINATE the trigger, then
STOP the immune response
Give Epi
maintain airway
/.Latex allergy: risks - Answer--frequent use of latex condoms
-healthcare workers
-allergy to avocados, bananas, and some nuts
/.Anaphylactic shock - Answer-AIRWAY--give epi IV or IM STAT and intubate if needed
BREATHING--apply O2; mechanically ventilate
CIRCULATION--monitor for distributive shock; give fluids
/.Epinephrine Auto-injector teaching - Answer-always carry 2 devices
inject by "stabbing" into top of thigh with pants on (AVOID pockets)
call 911 immediately--patient still needs to be monitored
keep epi in cool dark place.
/.Immunocompromised Patient - Answer--Do not drink anything that has been sitting out
-take temp at least once per day
-clean toothbrush once weekly in diswasher or bleach solution
, -do not eat raw foods; salad, cottage cheese
-do not scoop litter boxes
-no plants or soil exposure
-antibacterial soap
-AVOID reptiles
/.HIV: Assess - Answer-CD4 count
ELISA test once per year for at risk patients
/.HIV: Interventions - Answer-PREVENTION:
-condoms
-PreP (truvada) must take 4 consecutive days in a row before protected; cant miss more
than one dose in a row
-needle safety
-post exposure prophylaxis-start cART within 24-36 hours of exposure
/.HIV: Nutrition - Answer-high calorie
high protein
low fat
small frequent meals
thrush--treat with anitfungal
/.HIV tx: HAART/cART - Answer-DOES NOT CURE
Does not prevent secondary/opportunistic infections
MUST TAKE 90% of the time --otherwise resistance will occur
/.HIV: complications --- AIDS - Answer-CD4 count less than 200mmhg
most likely to experience opportunistic infections
--I.e Pneumocystic jiroveci pneumonia (ASSESS AIRWAY!!)
consult pallative care/hospice
/.candida albicans - Answer--Hallmark sign-- white patches in the mouth
-"food doesnt taste right"
-If patient wants a coke they can have it! They just have to rinse mouth out with water
(fungus loves sugar)
/.tuberculosis - Answer-hallmark sign-- night sweats, high fever, cough
-airborne isolation
-do not trust TB skin test in client with HIV
/.Fungal pneumonia - Answer-ABC's
monitor ABG--if hypoxemia present
antifungal drugs IV
/.External Radiation - Answer--teach client to leave markings in place
-use sunscreen
ANSWERS
/. Lupus: Hallmark sign - Answer-butterfly rash on face
/.Lupus: Indication of flare - Answer-Fever and fatigue
*also assess BUN function
*c reactive protein remains normal
/.Lupus: Interventions - Answer--Falls precautions
-treat pain with tylenol and NSAIDS (monitor kidney function)
-AVOID SUNLIGHT
-REPORT FLARE IMMEDIATELY
-clean skin with mild soap and pat dry and apply lotion
/.Lupus: medical management - Answer--hydroxychloroquine(anti-malarial) decreases
absorption of UV light
/.Scleroderma - Answer-inflammatory, autoimmune connective tissue disease
/.Scleroderma: Hallmark Sign - Answer-Hard, leather-like edematous skin
Late: esophageal dismotility
/.Scleroderma: Assess - Answer-Swallow safety--esophageal dysmotility (ASPIRATION)
O2
circulation
skin
/.Scleroderma: Interventions - Answer-aspiration precautions (keep HOB at 60 degrees
during meals and after)
skin protection measures
small frequent meals--avoid caffeine and alcohol
-avoid spices, caffeine and pepper
/.fibromyalgia: S/sx - Answer-extreme fatigure
GI symptoms
dysuria
blurred vision
forgetfulness
/.fibromyalgia: Assess - Answer-pain level
extreme fatigue
,GI symptoms
/.Fibromyalgia: Interventions - Answer-NSAIDS
Nuerontin (gabapentin)
Lyrica (pregabalin)
SNRI and tricyclic antidepressants (amitriptyline)
promote sleep and low impact exercise (stretching, walking, swimming, rowing, water
exercise)
/.Lyme Disease: Hallmark sign - Answer-stage 1: "bulls eye rash" and flu-like symptoms
Stage 2: facial paralysis, carditis, meningitis
/.Lyme Disease: Assess - Answer-Skin
history of tick bites
/.Lyme Disease: Interventions - Answer-prevention!
Insect repellant with DEET
early stage--doxycycline antibiotics ORAL
late stage--Iv antibiotics (ceftriaxone)
avoid tall grass
wear light colored clothing
have pets wear tick collars
/.Allergic Reaction Priority - Answer-STOP THE INFUSION/ELIMINATE the trigger, then
STOP the immune response
Give Epi
maintain airway
/.Latex allergy: risks - Answer--frequent use of latex condoms
-healthcare workers
-allergy to avocados, bananas, and some nuts
/.Anaphylactic shock - Answer-AIRWAY--give epi IV or IM STAT and intubate if needed
BREATHING--apply O2; mechanically ventilate
CIRCULATION--monitor for distributive shock; give fluids
/.Epinephrine Auto-injector teaching - Answer-always carry 2 devices
inject by "stabbing" into top of thigh with pants on (AVOID pockets)
call 911 immediately--patient still needs to be monitored
keep epi in cool dark place.
/.Immunocompromised Patient - Answer--Do not drink anything that has been sitting out
-take temp at least once per day
-clean toothbrush once weekly in diswasher or bleach solution
, -do not eat raw foods; salad, cottage cheese
-do not scoop litter boxes
-no plants or soil exposure
-antibacterial soap
-AVOID reptiles
/.HIV: Assess - Answer-CD4 count
ELISA test once per year for at risk patients
/.HIV: Interventions - Answer-PREVENTION:
-condoms
-PreP (truvada) must take 4 consecutive days in a row before protected; cant miss more
than one dose in a row
-needle safety
-post exposure prophylaxis-start cART within 24-36 hours of exposure
/.HIV: Nutrition - Answer-high calorie
high protein
low fat
small frequent meals
thrush--treat with anitfungal
/.HIV tx: HAART/cART - Answer-DOES NOT CURE
Does not prevent secondary/opportunistic infections
MUST TAKE 90% of the time --otherwise resistance will occur
/.HIV: complications --- AIDS - Answer-CD4 count less than 200mmhg
most likely to experience opportunistic infections
--I.e Pneumocystic jiroveci pneumonia (ASSESS AIRWAY!!)
consult pallative care/hospice
/.candida albicans - Answer--Hallmark sign-- white patches in the mouth
-"food doesnt taste right"
-If patient wants a coke they can have it! They just have to rinse mouth out with water
(fungus loves sugar)
/.tuberculosis - Answer-hallmark sign-- night sweats, high fever, cough
-airborne isolation
-do not trust TB skin test in client with HIV
/.Fungal pneumonia - Answer-ABC's
monitor ABG--if hypoxemia present
antifungal drugs IV
/.External Radiation - Answer--teach client to leave markings in place
-use sunscreen
