NUR 265 EXAM 4 - WITH COMPLETE SOLUTION.
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)
,NUR 265 EXAM 4 - WITH COMPLETE SOLUTION.
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!
, NUR 265 EXAM 4 - WITH COMPLETE SOLUTION.
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
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)
,NUR 265 EXAM 4 - WITH COMPLETE SOLUTION.
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!
, NUR 265 EXAM 4 - WITH COMPLETE SOLUTION.
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
