NUR 265 UPDATED EXAM ALL SCRIPTED QUESTIONS
AND ANSWERS SURE A+
✔✔Lyme Disease: Assess - ✔✔Skin
history of tick bites
✔✔Lyme Disease: Interventions - ✔✔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 - ✔✔STOP THE INFUSION/ELIMINATE the trigger, then
STOP the immune response
Give Epi
maintain airway
✔✔Latex allergy: risks - ✔✔-frequent use of latex condoms
-healthcare workers
-allergy to avocados, bananas, and some nuts
,✔✔Anaphylactic shock - ✔✔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 - ✔✔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 - ✔✔-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 - ✔✔CD4 count
ELISA test once per year for at risk patients
✔✔HIV: Interventions - ✔✔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 - ✔✔high calorie
high protein
low fat
small frequent meals
thrush--treat with anitfungal
✔✔HIV tx: HAART/cART - ✔✔DOES NOT CURE
Does not prevent secondary/opportunistic infections
MUST TAKE 90% of the time --otherwise resistance will occur
✔✔HIV: complications --- AIDS - ✔✔CD4 count less than 200mmhg
most likely to experience opportunistic infections
--I.e Pneumocystic jiroveci pneumonia (ASSESS AIRWAY!!)
consult pallative care/hospice
✔✔candida albicans - ✔✔-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 - ✔✔hallmark sign-- night sweats, high fever, cough
-airborne isolation
-do not trust TB skin test in client with HIV
✔✔Fungal pneumonia - ✔✔ABC's
monitor ABG--if hypoxemia present
antifungal drugs IV
✔✔External Radiation - ✔✔-teach client to leave markings in place
-use sunscreen
-wash skin with mild soap and use lotion frequently
✔✔Breast Cancer: Risks - ✔✔-BRCA 1&2 genes (preventative mastectomy)
-women age 65-80
-elevated estrogen levels
-alcohol consumption
-history of child after 30 years of age
-early menstruation or late menopause
✔✔Breast cancer: Assess - ✔✔screening history: mammography every year starting at
45***
-self exam frequency (same time of the month)***
-breast appearance (dimpling, orange peel appearance)
-breast ultrasound if have dense breast tissue; if cant get good mammography image***
✔✔Breast Cancer: interventions - ✔✔pre and post lumpectomy/mastectomy
**prophylactic mastectomy is patient with BRCA 1 and 2 gene
-then external radiation
-chemo
-symptom management
✔✔Lung Cancer: Risks - ✔✔-environmental exposure
-radon, environmental tobacco smoke, asbestos
-genetic
-inhalant exposure
✔✔Lung Cancer: Warning signs - ✔✔-hoarse voice**
-persistant cough**
-blood-tinged sputum**
-chest pain
AND ANSWERS SURE A+
✔✔Lyme Disease: Assess - ✔✔Skin
history of tick bites
✔✔Lyme Disease: Interventions - ✔✔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 - ✔✔STOP THE INFUSION/ELIMINATE the trigger, then
STOP the immune response
Give Epi
maintain airway
✔✔Latex allergy: risks - ✔✔-frequent use of latex condoms
-healthcare workers
-allergy to avocados, bananas, and some nuts
,✔✔Anaphylactic shock - ✔✔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 - ✔✔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 - ✔✔-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 - ✔✔CD4 count
ELISA test once per year for at risk patients
✔✔HIV: Interventions - ✔✔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 - ✔✔high calorie
high protein
low fat
small frequent meals
thrush--treat with anitfungal
✔✔HIV tx: HAART/cART - ✔✔DOES NOT CURE
Does not prevent secondary/opportunistic infections
MUST TAKE 90% of the time --otherwise resistance will occur
✔✔HIV: complications --- AIDS - ✔✔CD4 count less than 200mmhg
most likely to experience opportunistic infections
--I.e Pneumocystic jiroveci pneumonia (ASSESS AIRWAY!!)
consult pallative care/hospice
✔✔candida albicans - ✔✔-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 - ✔✔hallmark sign-- night sweats, high fever, cough
-airborne isolation
-do not trust TB skin test in client with HIV
✔✔Fungal pneumonia - ✔✔ABC's
monitor ABG--if hypoxemia present
antifungal drugs IV
✔✔External Radiation - ✔✔-teach client to leave markings in place
-use sunscreen
-wash skin with mild soap and use lotion frequently
✔✔Breast Cancer: Risks - ✔✔-BRCA 1&2 genes (preventative mastectomy)
-women age 65-80
-elevated estrogen levels
-alcohol consumption
-history of child after 30 years of age
-early menstruation or late menopause
✔✔Breast cancer: Assess - ✔✔screening history: mammography every year starting at
45***
-self exam frequency (same time of the month)***
-breast appearance (dimpling, orange peel appearance)
-breast ultrasound if have dense breast tissue; if cant get good mammography image***
✔✔Breast Cancer: interventions - ✔✔pre and post lumpectomy/mastectomy
**prophylactic mastectomy is patient with BRCA 1 and 2 gene
-then external radiation
-chemo
-symptom management
✔✔Lung Cancer: Risks - ✔✔-environmental exposure
-radon, environmental tobacco smoke, asbestos
-genetic
-inhalant exposure
✔✔Lung Cancer: Warning signs - ✔✔-hoarse voice**
-persistant cough**
-blood-tinged sputum**
-chest pain
