NUR 2571Exam 2 Review-finishedNUR 2571Exam 2 Review-finished, Exams of Nursing

Download NUR 2571Exam 2 Review-finishedNUR 2571Exam 2 Review-finished and more Exams Nursing in PDF only on Docsity! Exam 2 Review-finished. GRADED A 1) Child with allergic rhinitis ○ patho: exposure to sensitizing agent, body initiates inflammatory response releasing histamines and leukotriene. Blood vessels of nasal mucosa vasodilate causing increase permeability to affected area ○ causes swelling and nasal congestion ○ exhibit a triad of signs: i) the allergic shiner-a darkening of the lower eyelid because of suborbital edema) ii) the allergic crease-a transverse line above the tip and below the bridge of the nose iii) the allergic salute (frequent wiping of the nose with the palm of the hand) Other signs commonly present are a nasal quality to the voice, constant coughing from a postnasal drip, chapped lips, and a dry mouth from mouth breathing. ○ Can be infectious or non-infectious: Infectious = common cold. Non = allergic (seasonal) and nonallergic (pregnancy, inhaled drugs, humidity) 2) Anti-histamine that doesn’t cause drowsiness ○ Allegra (can be in the form of nasal spray or saline spray) ○ (1st gen = benedryl, 2nd gen = allegra – no drowsiness, fatigue, or dry mouth) Side effects: anticholinergic effects (dry mouth, constipation), GI discomfort (N/V, constipation), Acute toxicity (flushed face, high fever, tachycardia, dry mouth, urinary retention, pupil dilation), excitation, hallucinations, incoordination, and seizures *SEDATION EFFECT * ○ -Use with caution with clients with asthma, urinary retention, open-angle glaucoma, hypertension, and BPH ○ -can cause respiratory depression ○ -Do not give to clients with cardiac dysrhythmias, hepatic disease, and MAOI therapies 3) Teaching for client w/allergic rhinitis ○ keep windows closed* ○ run air conditioning* ○ remove carpeting to reduce pollen and humidity. * ○ remove pets if possible, If unable to remove pet, keep it out of the bedroom* ○ do not use feather pillows, and put pillows in zippered, dust proof encasings, Replace feather or down-filled covers and pillows with synthetic items* ○ wash linen in hot water* ○ POLLENS i) • Avoid freshly cut grass; do not mow the lawn. • Keep windows and doors closed during allergy season. • Shower after outdoor activities to remove pollen from clothing and skin. ○ MOLDS Exam 2 Review-finished. GRADED A i) • Clean damp areas frequently, at least once a week, with a chlorine bleach solution. • Ventilate areas well (bathrooms, kitchens, and basements). • Consider a dehumidifier if living in a humid climate. ○ PETS i) • Reduce cat allergen by bathing the cat every two weeks ○ IRRITANTS i) • Avoid cigarette smoke, perfumes, aerosol sprays, strong cleaning products 4) Tonsillectomy: know what to expect after and what is abnormal post op Diagnostics: ○ Throat culture for group A strep. & bacterial infection ○ CT if infection present to see if it spread to neck region ○ Pre-op CBC to assess for anemia/infections Tonsillectomy Education: ○ Report= signs of hemorrhage, fever, excessive vomiting of bright red blood, unrelieved pain, excessive coughing or swallowing (means a child can be swallowing blood)- abnormal ○ pt will have pain, difficulty swallowing, and difficulty talking ○ Drink minimum 8 glasses of water a day ○ Soft foods for first few days ○ Avoid smoking & heavy lifting ○ No gargling – can irritate surgical site ○ Sore throat is expected for approximately 1 week postop ○ Provide pain control with analgesics and ice collar postop ○ Offer clear, chilled fluids or ice pops to relieve pain and reduce inflammation when awake and alert ○ avoid red-colored liquids because emesis of these fluids could be mistaken for blood 5) Pneumonia risk factors ○ from slide: most at risk for pneumonia os sickle cell pt with a cough! ○ Acute or chronic infection of one or both lungs caused by bacteria or virus, upper respiratory infection ○ Increased age (group in nursing homes, over 50 yrs) ○ Immunocompromised (infants typically between 6 and 23 months, pregnancy women during flu season, long term treatment with steroids) ○ smokers ○ Diabetes ○ CHF ○ Active malignancies (cancer pts) ○ Chronic diseases (i.e. sickle cell anemia, asthma, kidney diseases, diabetes) (*if a question pops up about nsg intervention, PUSH FLUIDS TO LOOSEN UP SECRETIONS) 6) COPD physical assessment (question will only regard COPD not CHF) Exam 2 Review-finished. GRADED A · Chronic lung diseases (COPD, Cystic Fibrosis) · Left HF Medications Used: -typically diuretics (lasix, thiazides) 12) Asthma pt, what position should you put them in to facilitate breathing ○ high fowler’s position Additional info: · Characterized by exacerbations of acute airway inflammation · Airway obstruction occurs d/t bronchoconstriction, mucous, or inflammation when exposed to trigger Clinical Manifestations: · High pitched, wheezing lung sounds · Cough · SOB · Chest tightness · Worsens at night or when triggers are present Exacerbation Interventions: · Give short-acting beta agonist · IV corticosteroids depending on severity · O2 via nasal cannula · Calm atmosphere Questions: If a pt. is having an asthma attack how would you expect it to affect their VS? · At first RR increased then decreased as attack progresses · Tachycardia >120 · Decreased BP What are rescue medications for Asthma? · Short-acting beta agonists (Albuterol) 13) Albuterol, Proventil, Ventolin, serevent, know what they are and what is different, how used*** ○ Medications: i) Short Acting= (1) Albuterol : bronchodilator, rescue inhaler -treat or prevent bronchospasm. -albuterol cause nervousness, shakiness and jittery (from slide) (2) Proventil: bronchodilator -treat or prevent bronchospasm (3) Ventolin: bronchodilator -treat or prevent bronchospasm ii) Long Acting= Salmeterol (serevent) (1) beta 2-adrenergic agonist for acute asthma attack Exam 2 Review-finished. GRADED A (2) prevents asthma attack, not for an attack, pt are usually always on it, generally do not come off it iii) Corticosteroids= Serevent, Advair (1) good oral care, swish and spit, as this med can cause thrush (Question: if a pt comes in having wheezes and SOB, treatment given but no audible breath sounds, what is the nurse best action? CHECK the AIRWAY) 14) Albuterol side effects -beta adrenergic agonist p.635 ○ bronchodilator given as metered dose inhaler ○ Prevention of bronchospasm and inflammatory problems within and outside the lung (103). Action: smooth muscle relaxant p. 568 ○ Teach patient to carry drug with them at all times-it can stop or reduce life threatening bronchoconstriction p.568 ○ Side effects include: www.rxlist.com i) 3 main ones need to know for test from class: tachycardia, tremors/hyperactivity, bronchospasms ii) Headache, dizziness, insomnia iii) Cough, hoarseness, sore throat iv) Runny/stuffy nose, N/V, dry mouth, throat v) Muscle pain or diarrhea 15) Know genetics of cystic fibrosis, how someone gets it ○ Autosomal recessive genetic pattern -from both parents: Class notes, below pg.79 ○ The trait may not appear in all generations of any one branch of a family. ○ • The trait often first appears only in siblings rather than in parents and children. ○ • About 25% of a family will be affected and express the trait. ○ • The children of two affected parents will always be affected (risk is 100%). ○ • Unaffected adults who are carriers (heterozygous for the trait) and do not express the trait themselves can transmit the trait to their children if their partner either is also a carrier or is affected. ○ • The trait is found about equally in male and female members of the same family. 16) Assessment of CF,what to expect -(CF blocks the chloride transport in the cell membranes) ○ Clubbing nails, Salty skin, bulky malodorous BM - class notes ○ Ask in family history section of interview ○ PaO2 will be decreased ○ Formation of thick mucus with little or no water content p.563 i) causes problems in lungs, pancreas, liver, salivary glands and testes causing organ dysfunction and atrophy Exam 2 Review-finished. GRADED A ii) Non-pulmonary problems: pancreatic insufficiency, malnutrition, intestinal obstruction, poor growth, male sterility and cirrhosis of the liver, diabetes mellitus and osteoporosis. 17) Normal ABGs Pg. 188 ○ pH 7.35-7.45 ○ paCO2 35-45, ○ HCO3 22-26, ○ paO2 80-100, ○ SaO2 95-100% Heart Failure: -Heart cannot efficiently pump blood throughout the body – heart doesn’t fill with enough blood or pump with enough force -Compensates by increasing HR which dilates ventricles (increased HR = decreased cardiac output) Diastolic HF: -Inability to relax, causes decrease in ventricular filling Systolic HF: -Inability of the ventricles to contract and pump blood adequately -More common – r/t aging d/t stiffness of vasculature 18) Dx test for heart failure, which one tells you degree of failure pg. 65 ○ BNP measures the degree of heart failure ( notes) i) ↑BNP left ventricle pumps BNP: can’t pump enough to meet body needs (notes) ii) BNP – brain natriuretic peptide test: blood test for the amount of BNP in the heart and determines heart function, checks for heart failure. -Test will be done if doctor suspects heart failure based on edema and dyspnea. ○ Troponins -myocardial muscle enzyme that indicates muscle injury. i) Troponin T and I are not found in healthy people ii) Indicates cardiac necrosis or acute MI iii) marker present hours after onset of chest pain. ○ Other DX Tests i) Blood pressure ii) EKG: is the main test it shows structure, blood flow through the heart. iii) Cardiac cath iv) X-ray -PA, AP, MRI v) Ejection Fraction (EF): How much blood heart is spitting out with each beat [normal is 55-65%; lower the number the worse ○ More Labs (found in chapter 33 p. 655- 657) i) Homocysteine - elevated values independent risk for developing CVD ii) Microalbuminuria -endothelial dysfunction in cardiovascular disease Exam 2 Review-finished. GRADED A Clinical Manifestations: · Thickened nail beds · Intermittent claudication · Cramps in legs after exercise · Blackish ulcerations on skin · Extreme sensitivity to hot & cold · Pain in digits · Weak/thready peripheral pulses 25) Raynaud's manifestations p.741 -(similar interventions & implications as Buerger’s disease) -Bilateral vasospasms ; peripheral artery occlusive disease triggered by cold & stress ○ painful vasospasm of arteries & arterioles in extremities causing restriction of blood flow ○ Pain & cyanosis followed by redness and pain (when warmed up) ○ Pain is intermittent, extremities are numb & cold & may have swelling/ulcerations ○ Gangrene occurs when disease progresses in severity ○ red-white-blue skin color changes when exposed to cold or stress ○ seen more in women ○ possible autoimmune disease ○ often associated with rheumatic diseases such as systemic lupus erythematosus, systemic sclerosis, connective tissue diseases Education: · Stop smoking · Exercise · Control stress, monitor VS, esp BP due to risk of postural hypotention · Avoid extreme temperatures (cold and hot), avoid sharp objects Peripheral Arterial Disease (PAD) 26) Tx for peripheral arterial occlusion (PAD) p. 737 - 738. ○ IV heparin therapy to decrease clot formation and may be given in a bolus up to 10,000 U, Anti-coagulants, BP Meds. (Increased BP = Bleeding = not good) ○ antiplatelet (aspirin), use of fibrinolytic (to break clot) ○ Without immediate intervention, ischemia and necrosis will result within hours. The nurse should first wrap the leg to maintain warmth and protect it from further injury. The leg should not be elevated above heart level because doing so would worsen the tissue ischemia. The nurse should quickly notify the physician after taking an action that will benefit the client’s status. Passive range of motion will increase ischemia by increasing tissue demand for oxygen. -If pt comes in with pulselessness and pain, start heparin and monitor PTT Exam 2 Review-finished. GRADED A 27) Assessment for peripheral arterial occlusion S/S = 6 P’s i) pain (w/activity and rest)⇒ paresthesia (numb and cold)-early s/s ii) pallor (pale skin)⇒ poikilothermy (coolness) (1) poikilocythemia (irregular shaped RBC, abnormal variance in shape) iii) pulselessness ⇒paralysis -Intermittent claudication : caused by too little blood flow, usually during exercise ○ Surgical treatment called thrombectomy or embolectomy under local anesthesia to remove occlusion via catheter and possible patch graft. ○ PAD-Avoid tight stockings – constrict veins, lower affected extremity ○ PVD – encourage tight stockings, and elevate to allow blood flow to the heart -Define: arteries of the lower extremities and is characterized by inadequate flow of blood resulting from atherosclerosis (thickening of the intima and media of the arteries causing narrowing) - Assessment: - Burning, cramping, pain, numbness in legs when exercising, in bed, or in dependent position - bruit over femoral and aortic arteries, decreased capillary refill, decreased palpable pulses,dry skin, thick toenails, cold extremities, pallor extremities when elevated, dependent rubor (redness), muscle atrophy, ulcers, gangrene -Patient teaching - No crossing of the legs, no raising legs above heart, wear loose clothes, discourage smoking, no cold temperatures, educate about foot care (keep them clean, dry, wear good fitting shoes, never go barefoot, cut toenails across, or go to the podiatrist), teach relaxation techniques because stress increases vasoconstriction 28) Treatment for bleeding w/coumadin and w/heparin ○ treatment for bleeding with coumadin is vitamin K ○ heparin: protamine sulfate is the heparin antagonist used for excessive bleeding i) - 1-1.5 mg per 100U of heparin, do not exceed 50 mg within 60-90 minutes of heparin administration 29) Risk factors for varicose veins (incompetent valves leads to venous congestion and decreased venous blood return) ○ standing for long periods of time, genetics, hormonal changes, increase blood volume. ○ hereditary, pregnancy ○ avoid strenuous physical activity, avoid constrictive clothing, and increase in exercise (walking and swimming), weight reduction plan for obese, don’t cross legs, use compression stockings no occlusive stockings-impedes blood flow) Hypertension Exam 2 Review-finished. GRADED A 30) Teaching for HTN ○ lifelong management, how to check blood pressure at home, diet teaching, exercise. ○ will always have the diagnosis 31) Know what smoking does in relation to HTN ○ smoking thins vessels and causes vasoconstriction. This causes blood pressure to increase, increases heart rate, narrows the blood vessels, decreases elasticity. ○ 32) HTN manifestations ○ headaches (especially in morning), , flushing, ask if the pt. is a smoker, fatigue, chest pain, difficulty breathing. ○ usually asymptomatic, may cause HA particularly in the AM, dizziness, blurred vision, fainting, retinal changes, visual disturbances, nocturia. Most patients with prolonged high BP will have c/o of HA nurse should assess this while gathering information from the client. ○ 33) HTN stages and what the values of BP are ○ JNC7: Normal <120/<80, ○ Prehypertension: at risk, 120-139/80-89, ○ Stage 1 Hypertension 140-159/90-99, ○ Stage 2 Hypertension >159/>99 ** for exam, focus on preHTN stage, answer is 130-140 34) Exercise and HTN ○ exercise can lower blood pressure by 5-10 mmHg ○ Regular exercise makes the heart stronger, allowing it to pump blood with less effort, which reduces the force exerted on the artery walls and helps with weight loss. In addition to helping control blood pressure, regular exercise reduces the risk of MI, cerebrovascular accident (stroke), high cholesterol, diabetes, osteoporosis, and some cancers. 35) Modifiable and nonmodifiable risk factors for primary HTN ○ Non-modifiable risk factors: family history, gender men > women, age, race, genetics. ○ Modifiable risk factors: stress, obesity, high dietary intake of sodium or saturated fats, excessive caffeine, alcohol, or cigarette smoking. And oral contraceptives use use (Estrogen and progesterone – combo pills). ○ Secondary HTN: Renal Vascular diseases, Coarctation of aorta, primary hyperaldosteronism, hyperthyroidism, meds such as estrogens, and antidepressants, NSAIDs, and steroids. Interventions: · DASH diet = low fat & cholesterol - high grains, fruits & vegetables is rich in grains, fruits, vegetables, and low-fat dairy products, fiber, potassium, calcium, and magnesium - limits fat, saturated fat, and cholesterol. Reduction in blood pressure of 8–14 mm Hg in patients with hypertension who follow the DASH diet. · Avoid high sodium = canned foods, animal products (Keep sodium under 2400 mg)