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NS2882 Revision Exam Questions With
Correct Answers
Name the 3 main areas of the brain affected by Alzheimer's disease and explain the main functions of each area - ANSWER AD is associated with the loss of cells from the hippocampus, prefrontal cortex and limbic system.
- Prefrontal cortex: short -term (working) memory and motivation. Also has executive functions that allow past concepts and experiences to be applied to new problems - Hippocampus: associated with the regulation of emotion and memory, particularly long-term memory - Limbic system: contains the amygdala, hippocampus, thalamus, hypothalamus, basal ganglia and cingulate gyrus. Important functions in memory formation and emotional regulation Describe 2 changes that occur in the brain in a person with Alzheimer's Disease
- ANSWER Patients with AD develop: - Extracellular beta -amyloid plaque deposits - Neurofibrillary tangles - results in cellular structural changes leading to overall reduction in size of the brain Name 4 clinical manifestations of AD - **ANSWER • memory loss
- forgetfulness
- disorientation
- confusion** Write 2 potential problem statements followed by 2 nursing interventions for each of these potential problems related to a person suffering AD - ANSWER Problem statement 1 - Luciano is at risk of falls related to confusion and disorientation secondary to AD Interventions: **- Falls risk assessment
- Lower bed, rails up (although sometimes this becomes more dangerous as they** try to climb over) **- Place Luciano in a bed with a movement sensor alarm
- Place Luciano close to nurses' station** Problem Statement 2 - Luciano is at risk of isolation related to loss of confidence secondary to memory loss, confusion and disorientation
Interventions:
**- Encourage socialization
- Encourage involvement in group activities such as singing, music groups, art &** craft classes, exercise classes etc. Families of a person suffering AD often feel guilt and have an overwhelming feeling of grief, as they can see they are losing their loved one and in later stages a sense of relief knowing that the journey is coming to an end. Outline two (2) nursing interventions that can be implemented to help the family cope? - ANSWER • Provide education, assistance and reassurance to the family throughout all stages of the dementia journey. **- Provide information about respite services and community support services
- Share the small achievements of their loved one with the family** Case Study - ANSWER Actual Problem - ANSWER Nakita is experiencing a grand mal seizure related to her epilepsy as evidenced by whole body shaking and loss of consciousness Potential Problem - **ANSWER • Nakita is at risk of injury related to seizure
- Nakita is at risk of airway compromise related to seizure
- Nakita is at risk of brain damage related to possible prolonged seizure activity** Establish Goals - ANSWER • Nakita will not sustain in injury as evidenced by no evidence of injury on inspection while she is having a seizure - Nakita's seizure will not be prolonged > 5 - 10 mins as evidenced by cessation of seizure within the next 5 - 10 mins - Nakita's airway will not be compromised as evidenced by maintenance of own airway, RR 12-20 and spo2 >94% Take Action - ANSWER 1. Position for safety. Be sure client does not hurt himself/herself by falling off chair or against object. Try to lie client on floor if possible. Do not forcefully restrain or use bite stick. Remove objects that might injure client. Position client laterally (on side) using cushion or support.
- Call Met Call.
- Wait it out. Seizures generally run their course.
- Insert IV line (this would be done by experience nurse or doctor but you may need to assist).
- IV Diazepam (usually 5mg): if seizure does not subside within 5 minutes and airway is patent, and 5mg Diazepam IV after medical consultation. If seizure does not stop within a few more minutes, another 5 mg of Diazepam may be administered. Give slowly (1-2 mg/minute).
- Keep client lying down following seizure until MET team arrives. Client may remain unconscious, be confused or appear partially paralysed.
- Administer O2 at 4-6 L/min until fully recovered. Continue to monitor VS and 02 saturation.
Due to the status epilepticus, Daniel is treated with IV diazepam. Explain how the benzodiazepines are effective in interrupting status epilepticus - ANSWER Benzodiazepines act on the BZD site In normal doses, it augments GABA receptor receptiveness to GABA GABA hyperpolarises cells decreasing the chance of an action potential forming Daniel is prescribed an anti-epileptic druge - valproate (Valproic Acid). Contrast the different mechanism of action of carbamazepine and valproate - ANSWER They are both sodium channel and sodium flux effectors - and promote sodium removal. Carbamazepine stabilises the cell membrane and reduces the hyper-excitability of the nerve cell by delaying recovery of the sodium channels in the refractory period and promoting intracellular movement of Na out of the cell. Inhibits the formation of action potentials in the neurons to prevent seizures. Valproic acid extends the refractory period of sodium channels, but it also decreases calcium influx into the cell and increases the release of GABA (inhibitory action) and decreases GABA breakdown Identify two (2) key teaching points you will provide to Daniel prior to his discharge to help him manage his epilepsy. Provide a rationale for each teaching point. - ANSWER • AEDs must be taken as ordered - to maintain therapeutic levels (even if seizure free!)
- Keep seizure diary - ongoing management and to have an accurate record to share with GP The most important neurological assessment you can do is a Glasgow Coma Scale (GCS). What are the three (3) neurological responses assessed when assessing GCS - ANSWER Eye opening / Verbal response / Motor response What is the lowest GCS and what is the highest GCS? - ANSWER Score from 3 (no response)-15 (normal). At what point should you report a change in GCS - ANSWER Even a drop in score by one is significant and should be reported immediately When completing your neurological assessment, what other assessments (besides GCS) are recorded on the neurological observation chart - ANSWER - Pupillary reaction
- Limb strength
- Vital signs When you walk into the room to perform neurological observations on Margaret, she is fast asleep. Should you wake her to do your obs or should you allow her to sleep to rest her brain? - ANSWER YES! Always wake your patient to perform neuro obs!
What acute neurological impairment is known to reduce GCS score? - ANSWER Increased intracranial pressure (ICP) Explain the Monro-Kelly Hypothesis - ANSWER There are 3 component within the rigid skull brain tissue - 80% / blood - 10% / CSF - 10% An increase in one component must be compensated by a decrease in one or more of the other components so that intracranial pressure (ICP) remains constant. Otherwise ICP will rise. Describe four (4) nursing interventions you would implement to reduce Mr. N's ICP? - ANSWER • Elevate head of bed 30 degrees
- Maintain head and neck alignment avoiding hip flexion (promotes venous drainage) **- Reduce environmental stimuli
- Pain management** Q1. Identify 4 safety precaution that you will set in place while Mrs. Bishop has an epidural in progress. - **ANSWER • Patient must have a patent IV cannula
- No additional oral or parenteral analgesia or sedation is to be prescribed** unless approved by APMS **- All patients must have continuous O2 2l via NP at a minimum
- NEVER disconnect the filter from the epidural catheter** Q2. Identify the observations you will include in Mrs. Bishop's care plan while she has an epidural in progress - **ANSWER • Hourly for 8 hours
- 2 hourly thereafter
- 5 minutely for 20 mins after initial or any subsequent loading dose
- Patient MUST be woken to assess sedation score
- Pain score at rest and on movement (can they take a deep breath and cough?)
- Reservoir volume documented 2 hourly
- Bromage score documented 2 hourly
- Epidural site inspection 8 hourly
- Temperature, at least 8 hourly** Q3. It is 2 am in the morning, Mrs. Bishop's last epidurals observations were completed at midnight. She took some time to resettle after been woken for last assessment. You are doing rounds with your clinical partner and Mrs. Bishop appears to now be sleeping comfortably. Your partner suggest you do-not wake her during this round of assessment. What is your response? Justify your answer. - ANSWER All patients must be woken for the sedation score to be assessed accurately. This is policy along with a safety issue for the patient. You are unable to evaluate over sedation if you do-not wake the patient. Q4. You are carrying out pressure area care on Mrs. Bishop. You roll her and inspect her epidural site. Describe the type of dressing you would expect to see, how the catheter should be secured and lines that should be in place. Explain
Q8. Despite use of the PCEA Mrs. Bishop is now experiencing significant pain. Explain how results from a blockade assessment can assist determine the cause of this. - ANSWER Height
**- Failure in block to extend to adequate height
- Asymmetrical block** Density - Block extends to adequate height but inadequate analgesia "cold" but not "icy cold" Patchy block - Missed segments Q9. It is now 2 days since Mrs. Bishop's operation. She is progressing well and pain is well controlled. APMS has ordered for her PCEA to be removed. Explain the safety aspects and care relating to epidural catheter removal - ANSWER •Only remove on APMS ad vice. •Confirm if anticoagulants have been given. - Heparin/Enoxaparin to be withheld morning of removal (usually 12 hours prior), no anticoagulants until 4 hours post removal. •Follow APMS removal time as notated on Epidural Prescription. Why does your preceptor think your client may need a transfusion? - ANSWER Showing signs and symptoms of low HB (dyspnoea on exertion, fatigue, low Spo2) as well as hypovolemia with a background of recent blood loss from theatre. Why would it be important that Ms Bishop has a minimum of a 20 gauge cannula IV? - ANSWER Blood is quite viscous and requires a larger gauge cannula to run smoothly. What bloods must be taken before a transfusion can be provided? - ANSWER Crossmatch and group and hold What signs and symptoms will your patient exhibit if they experience the following blood transfusion complications? - ANSWER Haemolytic reaction: characteristically begins with an increase in temperature and pulse rate. Symptoms may include chills, rigors, dyspnoea, chest and/or flank pain, discomfort at infusion site, sense of dread, abnormal bleeding and may progress rapidly to shock. Circulatory overload: Dyspnoea, cough, pink frothy sputum, hypertension Allergic reaction: Hives, rash, flushing, wheeze, hypertension Febrile reaction:
Patients present with an unexpected temperature rise (≥38ºC or ≥1ºC above baseline, if baseline ≥37ºC) during or shortly after transfusion. This is usually an isolated finding. Occasionally the fever is accompanied by chills. Chills, rigors, increased respiratory rate, change in blood pressure, anxiety and a headache may accompany this reaction but may also occur in several more serious transfusion reactions also, the most serious being acute haemolytic reaction, transfusion transmitted bacterial infection and TRALI. FNHTR is a diagnosis of exclusion. Sepsis secondary to bacterial contamination: Clinical features suggesting the possibility of bacterial contamination and/or endotoxin reaction may include rigors, high fever, severe chills, hypotension, tachycardia, nausea and vomiting, dyspnoea, or circulatory collapse during or soon after transfusion. In severe cases, the patient may develop shock with accompanying renal failure and disseminated intravascular coagulation (DIC). This reaction may be fatal. What are the steps to prepare for transfusion? And what checks do you perform prior to administering the blood? - ANSWER Ask Madge her full name and date of birth and check this against her arm band and blood form.Blood cannot be administered if there is no arm band Check the blood product against the order - 7 rights - PRBC, platelets, FFP etc. Check the blood pack - right blood group, does this match Madge? Blood donation number matches the order, expiry date, how long has it been out of the fridge.Ensure the integrity of the bag, no clots or discolouration If Madge is A positive, can she have O negative blood? - ANSWER Yes If Madge is A positive, can she have O positive blood? - ANSWER Yes If Madge is B negative, can she have O positive blood? - ANSWER No
- Angela experienced PID as a 19 year old, identify the 2 main causative agents of PID - ANSWER Untreated cervicitis with the main causative organism Chlamydia trachromatis and Neisseria gonorrhoeae Mirena (progestin-releasing IUD) acts as a contraceptive by continuously releasing a low progesterone. Explain the physiological changes Mirena will cause to achieve a contraceptive effect. - ANSWER Progesterone causes the mucus in the cervix to thicken which prevents the passage of sperm through the cervix, may also make the endometrium thin and inhibit fertilization (inhibits sperm mobility and function) Identify 2 benefits of using an IUD over the oral contraceptive - ANSWER - Lower side effects
- Removes missed pill effect
- The GP suspect Helen may be suffering from gonorrhoea. Identify 4 signs and symptoms that has led to this suspicion? - ANSWER - Dysuria
- Vaginal discomfort
- Irregular bleeding
- Purulent discharge Type 1 Diabetes - ANSWER T1DM is a lifelong autoimmune disorder in which the beta cells in the pancreas are destroyed and the body is no longer able to produce insulin. This disease is not linked to modifiable lifestyle factors, it cannot be prevented and there is not cure. People with T1DM require exogenous insulin to maintain life.
- The Pancreas beta cells (Islets of Langerhans) produce little or no insulin.
- Most often occurs in childhood/adolescence
- Is characterized by hyperglycemia, a breakdown of body fats and proteins, and ketosis
- Managed with lifelong insulin replacement - injections or insulin pump
- The manifestations of Type 1 DM are the result of a lack of insulin to transport glucose across the cell membrane into the cells Type 2 diabetes - ANSWER Progressive condition - body becomes resistant to effects of insulin or production gradually decreases Cause unknown, but is linked to modifiable risk factors
- A condition of fasting hyperglycaemia that occurs despite the availability of endogenous insulin
- Occurs at any age, usually in middle age or older persons
- The level of insulin produced varies in T2DM and despite its availability, its function is impaired by insulin resistance
- Insulin resistance forces the pancreas to work harder to produce more insulin, but when demand for insulin exceeds supply, it results in DM Non-modifiable risk factors:
- People with Impaired Glucose Tolerance or Impaired Fasting Glucose
- Aboriginal or Torres Strait Islander, Melanesian, Polynesian, Chinese, Southeast Asian, Middle Eastern or from the Indian sub-continent
- 40 years or older
- a history of Gestational DM
- polycystic ovary syndrome (PCOS)
- Family History of DM Modifiable risk factors:
- history of Hypertension
- Overweight
- Inactive lifestyle
- Smoker
- Excessive alcohol
- Compare and contrast the aetiology of type 1 diabetes with type 2 diabetes - **ANSWER • Type 1 diabetes mellitus is a deficiency in insulin secretion
- Type 1 is usually caused by autoimmune destruction of the beta cells in the** pancreas **- Type 2 diabetes is caused by insensitivity of tissues to circulating insulin
- Insulin insensitivity may also be accompanied by reduced insulin secretion
- Effect of both conditions is that glucose cannot be absorbed by cells in the** body (esp skeletal muscle, fat and liver) so glucose absorbed from a meal stays in the blood for a long time. **- Lipids and ketones are mobilised to supply tissues with energy
- In most cases of type 2 diabetes there is still some insulin secreted by the** pancreas so there is usually less ketosis
- Why does Craig need a HbA1c test, and what is the relevance to diabetic persons? - ANSWER This measures the average plasma glucose concentration over a 12 week period and indicates how well glucose levels are controlled.
- What is HbA1c and what is the relevance to diabetic persons? - ANSWER This measures the average plasma glucose concentration over a 12 week period and indicates how well glucose levels are controlled.
- Describe the effects of insulin on the body and how these actions alter blood sugar levels - ANSWER - Insulin stimulates insertion of the insulin sensitive glucose transporter (Glut 4) into the plasma membrane of cells, especially in skeletal muscle and adipose
- This means that insulin stimulates tissue absorption of glucose from blood, which lowers blood glucose concentrations
- Insulin stimulates the liver to store glucose as glycogen, muscle to store glucose as glycogen, and adipose to convert glucose to fat.
- In addition it suppresses gluconeogenesis and lipolysis and promotes growth
- Craig is diagnosed with Diabetic ketoacidosis, what signs was he displaying that would lead to this diagnosis - ANSWER Elevated BSL above 13.9 mmol/L, Dry mouth, thirst, Confusion, Lethargy, Increased urination, Nausea & vomiting, Abdominal cramps, Rapid weak pulse, ketonuria, ketosis
- List 2 others signs not identified in the case study that may indicate diabetic ketoacidosis - ANSWER Breath odour - 'Fruity' - Ketones Deep laboured breathing (Kussmaul breathing) Flushed dry skin, Sunken eyes, Fever, Glycosuria
inactivate tumor suppressor genes and cause proliferation of DNA damaged cells that drive a cell toward cancer. 3a) What is metastasis? - ANSWER Spread of cancer cells to distant sites and formation of new tumors in tissues and organs away from the primary site of the tumor origin. 3b) Why liver is the most common site of metastasis for colon cancer? - ANSWER Venous blood leaving the colon and rectum flows through the portal vein into the liver, hence colorectal cancer cells that gain entry to the venous blood form colony in the liver. 4a) Why is determination of grade and stage of the tumor as a part of a complete diagnostic evaluation is essential? - ANSWER Treatment options and prognosis are determined on the basis of staging and grading. 4b) Why cancers diagnosed at later stages are mostly not curable - ANSWER Metastasized is more aggressive and less responsive to treatment not possible to kill all cancer cells located at many sites. 5a) Why bowel cleansing and oral antibiotics were suggested before surgery - ANSWER To reduce colonic bacteria and to decrease post-operative infection and abscess formation. 5b) Why chemotherapy is recommended for Jay? - ANSWER Jays tumor has metastasized to distant sites. Chemotherapy is systemic therapy and capable of reaching cancer cells metastasized to distant sites.
- Jay is worried about side effects from the chemotherapy, why is chemotherapy accompanied with numerous side effects? - ANSWER Kills cells that multiply quickly, such as cancer or leukaemic cells. Also causes damage to fast-growing normal cells, including hair cells and cells that make up the tissues in the mouth, gut and bone marrow. The side effects of chemotherapy occur as a result of this damage.
- Identify 4 side effects of chemotherapy that Jay may experience - ANSWER Bone marrow - inability to produce adequate numbers of blood cells (white cells, platelets and red cells), Increased risk of infection, Nausea & vomiting, Changes to sense of taste and smell, Mucositis (inflammation of the lining of the mouth, throat or gut), Damage to lining of bowel wall - leads to cramping, wind, abdominal swelling, constipation and diarrhoea. Hair loss, Tiredness,
- For each side effect you identify, identify 1 nursing intervention - ANSWER Nausea & vomiting - Encourage patient to eat and drink when not nauseated; administer antiemetics prophylactically and PRN; diversional activities
- Explain the mechanism of action of Oxaliplatin (alkylating agent) & fluorouracil (antimetabolite) - ANSWER Both cause DNA damage; Interferes with cell division in proliferating cancer cells.
- Alkylating agents - Binds to DNA and stops it replicating
- Antimetabolites - DNA damage caused by interfering with DNA synthesis
- Why side effects commonly occur after treatment with cytotoxic drugs? - ANSWER Also interfere with cell division in highly proliferative normal tissues such as GI epithelium, bone marrow and skin
- What do you think might be the cause of these signs and symptoms? - ANSWER Possible infection related to neutropenia secondary to chemotherapy for breast cancer
- Provide the evidence that makes you think this may be the problem. - ANSWER Rigors, productive cough, yellow sputum, recent chemotherapy, lab results: pancytopenia (all blood count levels reduced) including neutrophils (neutropenia)
- What would account for these abnormal lab findings? - ANSWER Recent chemotherapy - causes damage to bone marrow which results in inability to produce adequate numbers of blood cells (white cells, platelets and red cells)
- What precautions do you need to put in place given Jane's situation? - ANSWER Reverse barrier nursing and cytotoxic precautions. Reverse barrier nursing involves: · The patient being admitted into an isolation room where the door must remain closed · Strict hand washing · Any person entering the room must protect the patient by wearing a gown, gloves and mask that must be put on before entering the room, and removed after leaving the room. Sometimes the patient will also opt to wear a mask to protect themselves, however, this is not necessary if everyone in the room is wearing a mask · Strict aseptic technique where possible during any procedures · Keeping visitors to a minimum - usually only 2 visitors at a time and family only. People who are unwell are not to visit. · Regular monitoring of temperature is vital as this may be the first and only sign of infection. · If infection is suspected, serial blood cultures may be required and intravenous antibiotics will be commenced as soon as possible. Administering IV antibiotics on time is vital. · It is also important to inform the family of the signs and symptoms of possible infection such as a high temperature. Particularly if they are being cared for at home. For a neutropenic patient, this is an emergency situation.
