NURS 600 Exam 5 2023 with complete solution questions and answers

Palpitation Sensory symptom that is an unpleasant awareness of the forceful, rapid, or irregular beating of the heart. Palpitation complaints by patients: Pounding sensation, rapid fluttering, flip-flopping Etiology of Palpitations: (3) Cardiac (43%) Psych (31%) Misc (10%) - Meds, Caffeine, Cocaine, Anemia Palpitation Etiology: Cardiac generally present to the: Psychiatric generally present to the: Cardiac - ED Psych - Outpatient Clinic Four variables which predict cardiac etiology for palpitations: Male Sex Description of irregular heart beat History of heart disease Duration 5 minutes "Flip Flopping" of heart Heart stops and then starts again. Generally related to: SVT or PVC Pounding in the neck may be related to: (3) PVC, 3rd Degree Heart Block, VTach ______ is a red flag when present with palpitations. Syncope/ Presyncope Major challenge for provider during clinical exam in patient complaining of palpitations: Absence of symptoms during visit mitral valve prolapse Improper closure of the mitral vale during systole. Mitral Valve Prolapse sound Mid Systolic Click _____ murmur that increases with valsalva with HCM. Harsh holosystolic Murmur Palpitations Diagnostics: EKG, Holter Monitor, Continuous Loop Recorder**, Implantable Loop Recorder True or False: Continuous Loop Recorders are better diagnostic indicators and more cost effective than holter monitors. True Atrial Fibrillation Rapid irregular beats within the atria. Supraventricular tachyarrhythmia characterized by disorganized and rapid atrial activation and uncoordinated atrial contractions. Atrial Fibrillation prevalence: ____% in population over the age of 80 Men Women Whites Blacks 80% have ______ 10% in those over the age of 80 80% have CV disease Atrial Fibrillation: Complex interaction between triggers for AF and abnormal ______ that has multiple reentrant circuits outside the SA node. Atrial Myocardium Rapid electrical activity in the atria produces disorganized and ineffective atrial contractions. Atrial Fibrillation Atrial Fibrillation: Rapid atrial electrical activity conducted through the ______ leads to an irregular ventricular response. AV node. Atrial Fibrillation may lead to _____ and/or thromboembolism. Cardiomyopathy Atrial Fibrillation leads to loss of: (2) Atrial Muscle Mass (Fibrosis) and Atrial Kick Loss of the atrial kick leads to reduced _____ by 15% Cardiac Output Atrial Fibrillation will shorten the: Diastolic Filling (ultimately reduces CO) Symptoms of Atrial Fibrillation: Palpitations, tachycardia, fatigue, weakness, dizziness, lightheadedness, reduced exercise tolerance, increased urination, mild dyspnea Serious reported symptoms associated with AF: Syncope, Presyncope, Dyspnea at rest, Angina, Embolism, Right Sided Heart Failure Physical exam for Atrial Fibrillation (blood pressure): (2) Postural Change and Assess for widened pulse pressure ______ valvular heart disease may cause AF. Mitral _______ should be excluded with Atrial Fibrillation. HYPERthyroidism ______ position may help to hear heart sounds associated with Atrial Fibrillation. Lateral Decubitus Position Murmurs often heard with Atrial Fibrillation: (2) Mitral Stenosis and Mitral Regurgitation ______ heart sound is NOT heard with Atrial Fibrillation as it is related to the atrial contraction. Fourth heart sound Causes of Atrial Fibrillation: Hypertension, HCM, Ischemic heart disease, Heart failure, Hyperthyroidism, Sick sinus syndrome, Pericarditis, Cardiac Surgery, Ethanol intoxication (Holiday heart), pulmonary embolism, catecholamine excess Wolff-Parkinson-White Syndrome Pre-excitation of the ventricles of the heart due to an accessory pathway known as the bundle of Kent. This accessory pathway is an abnormal electrical communication from the atria to the ventricles. WPW is a type of atrioventricular reentrant tachycardia. Has a "Delta Wave" on the EKG Diagnostics for AF should include: TSH/T4, Electrolytes, Tox Screen, CBC, Renal, LFT ECG, ECHO Pulmonary Embolism workup MUST include (protocol): D Dimer and Chest CT D-dimer test Global marker of coagulation activation and measures fibrin degradation products produced from fibrinolysis (clot breakdown). The test is used for the diagnosis of DVT/PE. Transesophageal Echocardiogram is helpful to evaluate: LEFT atrial thrombus (If thrombus present, cardioversion should be delayed.) Atrial Fibrillation rate: Atria: Extremely fast (350) Ventricles: Slow, Normal or Fast Atrial Fibrillation p-wave: Absent Atrial Fibrillation PR-Interval: Absent Treatment for AF depends on: Hemodynamic Stability of symptoms Hemodynamically UNSTABLE AF symptoms: Syncope, Presyncope, Hypotension, CHF, Angina Requires urgent referral and treatment** Hemodynamically STABLE AF treatment: Rate control and possible anticoagulation Atrial Fibrillation management aimed at: (2) Rate/Rhythm Control and Emboli Prevention Medication Classes for RATE control with AF: (3) Beta Blockers (Atenolol, Metoprolol) NONdyhydropyradine CCB (Verapamil & Diltiazem) Digoxin Example Medications for AF RHYTHM control: Dronedarone, Amiodarone, Sotalol, Dofetilide, Procainamide, Quinidine First line medications for RATE control in AF: (4) Atenolol, Carvedilol, Esmolol, Metoprolol CHAD score Risk assessment that determines a patient's risk for stroke secondary to AF. Determines if oral coagulation is needed. Anticoagulants (Ex: Warfarin) reduces stroke risk by ____ in patients with AF. Especially for nonvalvular patients. ... Patients with a CHAD score 2 should: Receive chronic anticoagulation Females with a CHAD score of 0 or 1: Do not require coagulation therapy ______ or _____ preferred over Warfarin in patient's at risk for stroke with AF. Oral direct thrombin inhibitor or Factor Xa Inhibitor Warfarin may be considered in patients: Compliant to regimen & INR's, cannot take multiple doses of alternative, severe kidney disease (GFR 30), Phenytoin, HIV patients on Protease Inhibitor therapy Cerebrovascular Accident (CVA) Interruption of blood circulation to the brain causing a neurologic deficit that reflects that specific area of the brain affected. 2 Type of CVA's: Ischemic & Hemorrhagic 2 forms of Ischemic Strokes: Lacunar & Transient Ischemic Attack (TIA) Most prevalent type of stroke: Ischemic Most lethal type of stroke: Hemorrhagic Type of ischemic stroke that is most prevalent in older adults or individuals with DM: Lacunar Type of ischemic stroke that causes brief focal deficits caused by vascular occlusion. TIA Most lethal type of a stroke that generally affects younger/healthier adults. Hemorrhagic CVA: _____ leading cause of death for men. _____ leading cause of death for women. 5th -- Men 3rd -- Females Leading cause of disability in the US. CVA Stroke Belt Southeast US (Buckle Region includes: Georgia, NC, SC - 40% increased risk of stroke) Ischemic Strokes greater in: (2) African Americans and Hispanics Ischemic Strokes are a complication related to: Atherosclerosis (Reduced blood flow to the brain due to occlusion/blockage) Hemorrhagic Stroke related to: Ruptured Aneurysm Temporary reduction of blood flow to the brain from a partially occluded vessel. TIA Risks for CVA: HTN, Age, Smoking, Male, Family History, Race, TIA, Carotid Stenosis 80%, AF ______ are a risk factor for recurrent risk of stroke. TIA's Clinical presentation of CVA: Hemiparesis, hemisensory loss, visual field defects, ataxia, dysarthria, reflex asymmetry, Babinski +, cognitive and behavioral changes, NV, seizures, fatigue Headache is common in ______ stroke. Hemorrhagic Physical exam findings for CVA are specific to: Location of the vascular event and associated neurologic deficit. TIA's: Symptoms generally last _________ Less than an hour (may have permanent sequelae) CVA workup: CT without contrast, EKG, Chest XR, ABG's, CBC, PTT, glucose, BUN/Creat, electrolytes, carotid US, Holter, CSF, ESR, Stroke Assessment ABCD2 Scoring System for Elderly Prediction of Stroke: A: B: C: D: D: A: Age 60 B: Blood Pressure 140/90 C: Clinical Features (weakness & impaired speech) D: Duration (10-59 minutes = 1 point and 60 = 2) D: Diabetes The higher the score, the greater the risk** Subdural Hematoma Collection of blood under the dura mater in the brain. Symptoms of subdural hematoma LOC, grogginess, irritability, amnesia, seizures, numbness, headache, dizziness, weakness/lethargy, nausea/vomiting, personality changes, slurred speech, ataxia, altered breathing, blurred vision, deviated gaze Management of CVA Immediate ED referal and specialist consultation Parkinson's Disease Slowly progressive neurodegenerative disease with insidious onset of cardinal features which include asymmetric resting tremor, bradykinesia, rigidity, and postural changes. Mean age of diagnosis with Parkinson's Disease 70 Parkinson's more prevalent in: Males High risk for Parkinson's Disease with: 1st degree relative (risk doubles) Parkinson's Disease: Widespread degenerative changes in the: _______ Widespread depletion of ______ in the substantial nigra. Neuronal circuits interrupted. Basal Ganglia Dopamine 3 Types of Parkinson's Disease: 1. Tremor Dominant 2. Akinesia- Rigid 3. Postural Instability/Gait Difficulty Form of Parkinson's Disease with slower progression and less neuropsychiatric impairment. Tremor Dominant PD Symptoms of Parkinson's Disease: Unilateral tremor (pill rolling), rigidity, bradykinesia with freezing, flexed posture with loss of postural reflexes, rest tremor that disappears with action, slow coarse tremor, rigidity, cogwheeling, bowed head, trunk bent forward, kyphotic back, masked face, shuffling gait, monotonous tone, loss of automatic movement cogwheeling Ratchety movement due to superimposition of tremor on rigidity Festination Quick short steps "shuffling" - commonly seen in PD. Dysarthria Slurred speech related to reduced muscular tone PD workup: No diagnostic studies _______ cardinal manifestations must be present 2 of the 3 Management for PD: Selegiline, Levodopa, Dopamine Agonist, COMT Inhibitors, Anticholinergics, Amantadine Concussion Mild traumatic brain injury, where there is a disruption of brain function. May present with transient LOC with confusion. Radiographic testing will be negative.** ______% of patients with concussive injuries do NOT experience decreased LOC. 90% Concussion: Coup Injury Injury directly below the point of impact. Bruising appears on the side of the injury. Concussion: Contrecoup Injury Damage to the brain on the side OPPOSITE the point of a blow (result of the brain's hitting the skull). Primary Concussion Direct result from injury that occurs at the time of initial insult. Mechanical injury. Secondary Concussion Flow-metabolism mismatch. Complication of primary brain damage. Age risks for concussions: 0-4 15-19 65+ Military Grade I Concussion Transient confusion (5 minutes). No LOC. Grade II Concussion Confusion lasting 5-15 minutes. No LOC. Grade III Concussion Confusion, amnesia and LOC present. Retrograde amnesia Loss of memory from the past. Symptoms of a concussion: Transient LOC, retrograde amnesia, confusion, headache, NV, drowsiness, transient neuro deficit, vision changes, bradycardia/hypotension When to admit to hospital with concussion: Decreased LOC, seizures, focal deficits, vomiting, positive head CT findings Huntington's Disease Inherited progressive neurodegenerative disorder characterized by choreiform movements, psychiatric problems, and dementia. Trinucleotide (CAG) repeat expansion on Chromosome 4P. Results in autosomal dominant. Huntington's Disease Chorea Rapid, jerky, purposeless movement involving limbs, trunk, or face. Involuntary and nonrepetitive. Huntington's Disease may initially be diagnosed as: Restlessness. Initially the movements are mild in nature. Chorea may affect the diaphragm, pharynx and larynx, which may result in: Dysarthria, Dysphagia and Involuntary Vocalizations Huntington's Disease: ______- tonia _____ - reflexia HYPOtonia and HYPERreflexia Late stage/ disease progression HD: Chorea may change too _____ akinetic-rigid state Dyskinesia Difficulty initiating movement Akinesia Inability to initiate movement Workup for Huntington's Disease: Brain MRI/CT/PET, Gene Testing Huntington's Disease management: Dopamine Receptor Blocker Haloperidol Myasthenia Gravis Autoimmune disorder that affects the neuromuscular junction and is characterized by fatigue and weakness of voluntary muscles. Peak incidence of Myasthenia Gravis: Women 20-30's Men 60-70's Myasthenia Gravis Autoimmune disorder that attacks acetycholine receptors (AChR) at the postsynaptic junction. The decrease in Acetylcholine results in weakness with repeated activity and recovery with rest. Thymis Hyperplasia may be seen in _____ Myasthenia Gravis Myasthenia Gravis triad symptoms: Ptosis, Diplopia, Dysphagia Myasthenia Gravis symptoms: Blurry/double vision, choking sensation, difficulty chewing, slurring speech, fatigue, ptosis Myasthenia Gravis symptoms are more pronounced: When the individual is fatigue or in the evening Muscle weakness is increased with repetition or sustained activity. Myasthenia Gravis Myasthenia Gravis: Arm raise CANNOT be sustained. Upward and lateral gaze cannot be sustained longer than ____. 30 seconds. Voice quality and speech changes when counting out loud to 100. Seen in patients with: Myasthenia Gravis Normal coordination, sensory, and pupillary response in: Myasthenia Gravis Antibody titer for Aceytlcholine Receptor (AChR-Ab) is positive in ___% of patients with MG. 90% edrophonium (Tensilon) is used as workup for this diagnosis: (After the injection, there is an improvement of strength.) Myasthenia Gravis Cholinesterase-Inhibiting Drug Test (edrophonium (Tensilon)) is used for diagnosis of: Myasthenia Gravis MG workup: Repetitive muscle stimulation test will show: Decremental response Single fiber EMG used as diagnostic workup for: Myasthenia Gravis MG managementL Cholinesterase-Inhibiting Medications Plasmapheresis IVIG Steroids Pyridostigmine Neostigmine Multiple Sclerosis Chronic delmyelinating disease in which the insulating covers of nerve cells in the brain and spinal cord are damaged. MS more common in _____ and often diagnosed in early adulthood (20-50 years of age). Females MS lower risk populations include: Asian and African American MS pathogenesis: Unknown etiology. Possible linked to autoimmune, viral, environmental. Possible cell-mediated response to myelin sheath in individuals with linked genes. 4 types of MS: 1. Relapsing Remitting 2. Primary Progressive 3. Secondary Progressive 4. Progressing-Relapsing MS: Acute attacks with either a full recovery or some residual deficits between episodes. Relapsing Remitting MS MS: Steady disease progression. Possibly some plateaus and remissions. Primary Progressive MS MS: "Combination" -The condition begins as relapsing remitting and then changes to primary progressive. Secondary Progressive MS MS: Progression of disease with or without recovery. Patient is on a steady downhill course. Progressive-Relapsing MS Symptoms of Multiple Sclerosis: Visual changes, intermittent weakness/numbness, loss of balance, fatigue, dysphagia, constipation, vertigo, urinary incontinence, paresthesia, sensory loss Clinical findings with MS: Optic atrophy, + nystagmus, Babinksi, Spasticity, Loss of proprioception, impotence, impaired cognition, dysarthria, cerebellar/sensory deficits Workup for MS: CSF, MRI, CBC, Glucose MS management: (30 Steroids, Beta Interferon Therapy, Immunosuppressive Therapy Poor prognosis for MS: LATE onset (35 years of age) ___ symptoms are a POOR prognosis for MS. ____ symptoms are a GOOD prognosis for MS. Motor - Poor Sensory - Good Good prognosis for MS if there is minimal disability after ____ years. 5 Good prognosis for MS if there is only __ symptom the first year with a long remission period. 1