NUR 775 Unit 3 TB

NUR 775 Unit 3 TB NUR 775 Unit 3 Chapter 238: Blood Coagulation Disorders 1. A male patient has a history of recurrent epistaxis. Prior to a scheduled surgery, the provider asks about a family history of bleeding disorders. The patient reports no female relatives who had excessive bleeding episodes, but states that a maternal uncle and his maternal grandfather both had post-surgical complications related to bleeding. Based on this history, which diagnosis is possible? a. a. Hemophilia b. b. Thrombocytopenia c. c. Thrombophilia d. d. Von Willebrand disease ANS: A Hemophilia is an X-linked recessive disorder affecting only males and carried by females. A family history of maternal males with bleeding disorders should clue the provider that this disorder is likely. Thrombocytopenia is usually an acquired disorder. Thrombophilia causes clots and thrombi, not bleeding. Von Willebrand disease is an autosomal genetic disorder affecting both males and females. 2. A patient is noted to have prolonged bleeding after an intravenous needle is removed. A subsequent laboratory test reveals a prolonged activated partial thromboplastin (aPTT) time with a normal prothrombin time (PT). Based on this result, the provider may suspect alteration in function of which factor? a. a. Factor V b. b. Factor VII c. c. Factor VIII d. d. Factor X ANS: C Factor VIII is part of the intrinsic system, which aPTT measures. The other factors are part of the extrinsic system, which is measured by PT.REF: Pathophysiology 1. 3. A patient has type 1 Von Willebrand disease (vWD). What treatment is generally effective to prevent and treat bleeding episodes in this patient? a. a. Coagulation factor b. b. Desmopressin c. c. Heparin d. d. Vitamin K ANS: B Desmopressin may be useful in patients with type 1 vWD. Coagulation factor is used in most patients with hemophilia. Heparin is an anticoagulant. Vitamin K is used to counter warfarin overdose.REF: Von Willebrand Disease 1 NUR 775 Unit 3 Chapter 239: Leukemias 3. 1. A patient is suspected of having leukemia and the provider orders biochemical studies and a bone marrow aspirate and biopsy. The results include WBCs greater than 200,000 cells/mm3 normal RBCs, hyperplastic myeloid cells, and the absence of serum leukocyte alkaline phosphatase. Which test will the provider order to confirm a diagnosis in this patient? a. Chest radiograph b. Coagulation studies c. Philadelphia chromosome test d. Serum protein electrophoresis ANS: C The findings from the CBC and bone marrow biopsy, along with a positive Philadelphia chromosome test, confirm the diagnosis of chronic myelogenous leukemia. A chest radiograph and serum protein electrophoresis may be performed to evaluate for associated symptoms. Coagulation studies are usually performed as part of the diagnostic workup for ALL.REF: Clinical Presentation/Chronic Leukemias/Diagnostics and Differential Diagnosis 1. 2. A child has a recent history of leg pain, unexplained bruising, and nosebleeds. The provider notes petechiae and diffuse lymphadenopathy. A complete blood count reveals a WBC of 30,000 cells/mm3 and near normal RBC and platelet counts. What will the provider do next to manage this patient? e. a. Order coagulation studies to evaluate for coagulopathies f. b. Perform biochemical studies to look for hyperuricemia g. c. Refer to a specialist for a bone marrow aspirate and biopsy h. d. Repeat the complete blood count in two weeks ANS: C Patients with ALL may have normal blood counts even when the marrow has been replaced with leukemic cells, so a bone marrow aspirate and biopsy is required for the definitive diagnosis. Coagulation and biochemical studies may be performed after the diagnosis is known to evaluate for complications. Waiting and repeating the CBC in 2 weeks is not recommended since the definitive diagnosis is made by bone marrow biopsy.REF: Clinical Presentation/Acute Leukemias/Diagnostics and Differential Diagnosis 2. 3. A patient with acute myelogenous leukemia (AML) who has a high white blood cell count and diffuse lymphadenopathy is hospitalized during the induction phase of chemotherapy. What monitoring and interventions are critical to assess for complications during this phase of care for this patient? Select all that apply. e. a. Administration of sodium bicarbonate and allopurinol f. b. Assessment for bruising and petechiae g. c. Close monitoring of absolute neutrophil counts h. d. Daily renal function and chemistry values i. e. Meticulous assessment of hydration status ANS: A, D, E 2 NUR 775 Unit 3 This patient has a high WBC load and diffuse lymphadenopathy, so is at increased risk for acute tumor lysis syndrome (ATLS). Close monitoring of renal function, serum renal chemistry values, and hydration status is essential. Adding sodium bicarbonate and allopurinol help to minimize risk. Thrombocytopenia causing bruising and petechiae, along with neutropenia, are common complications of chemotherapy but these symptoms generally occur 7 to 10 days after initiation of therapy.REF: Tumor Lysis Syndrome Chapter 102: Acute Bronchitis 4. 1. An adult patient who had pertussis immunizations as a child is exposed to pertussis and develops a runny nose, low-grade fever, and upper respiratory illness symptoms without a paroxysmal cough. What is recommended for this patient? e. a. Azithromycin daily for 5 days f. b. Isolation if paroxysmal cough develops g. c. Pertussis vaccine booster h. d. Symptomatic care only ANS: A Adults previously immunized against pertussis may still get the disease without the classic whooping cough sign seen in children and are contagious from the beginning of the catarrhal stage of runny nose and common cold symptoms. Azithromycin or other macrolide antibiotics are useful for reducing symptoms and for decreasing shedding of bacteria to limit spread of the disease. Patients should be isolated for 5 days from the start of treatment. Pertussis vaccine booster will not alter the course of the disease once exposed. Symptomatic care only will not reduce symptoms or decrease disease spread. 2. 2. A patient develops a dry, non-productive cough and is diagnosed with bronchitis. Several days later, the cough becomes productive with mucoid sputum. What may be prescribed to help with symptoms? i. a. Antibiotic therapy j. b. Antitussive medication k. c. Bronchodilator treatment l. d. Mucokinetic agents ANS: B Antitussive medications are occasionally useful for short-term relief of coughing. Antibiotic therapy is generally not needed and should be avoided unless a bacterial cause is likely. Bronchodilator medications show no demonstrated reduction in symptoms and are not recommended. Mucokinetic agents have no evidence to support their use. REF: Communication and Language Development 3. 3. A patient develops acute bronchitis and is diagnosed as having influenza. Which medication will help reduce the duration of symptoms in this patient? j. a. Azithromycin k. b. Clindamycin l. c. Oseltamivir m. d. Trimethoprim-sulfamethoxazole 3 NUR 775 Unit 3 ANS: C Oseltamivir is an antiviral medication used to reduce the severity and duration of symptoms of influenza. The other medications are antibacterial medications and not effective to treat influenza. REF: Management Chapter 103: Asthma 5. 1. A patient who has asthma calls the provider to report having a peak flow measure of 75%, shortness of breath, wheezing, and cough, and tells the provider that the symptoms have not improved significantly after a dose of albuterol. The patient uses an inhaled corticosteroid medication twice daily. What will the provider recommend? i. a. Administering two more doses of albuterol j. b. Coming to the clinic for evaluation k. c. Going to the emergency department l. d. Taking an oral corticosteroid ANS: A The patient is experiencing an asthma exacerbation and should follow the asthma action plan (AAP) which recommends three doses of albuterol before reassessing. The peak flow is above 70%, so ED admission is not indicated. The patient may be instructed to come to the clinic for oxygen saturation and spirometry evaluation after administering the albuterol. An oral corticosteroid may be prescribed if the patient will be treated as an outpatient after following the AAP. REF: Management 3. 2. An adult develops chronic cough with episodes of wheezing and shortness of breath. The provider performs chest radiography and other tests and rules out infection, upper respiratory, and gastroesophageal causes. Which test will the provider order initially to evaluate the possibility of asthma as the cause of these symptoms? m. a. Allergy testing n. b. Methacholine challenge test o. c. Peak expiratory flow rate p. d. Spirometry ANS: D Spirometry is recommended at the time of initial assessment to confirm the diagnosis of asthma. Allergy testing is performed only if allergies are a possible trigger. The methacholine challenge test is performed if spirometry is inconclusive. PEFR is generally used to monitor asthma symptoms. REF: Diagnostics 4. 3. A patient is seen in clinic for an asthma exacerbation. The provider administers three nebulizer treatments with little improvement, noting a pulse oximetry reading of 90% with 2 L of oxygen. A peak flow assessment is 70%. What is the next step in treating this patient? n. a. Administer three more nebulizer treatments and reassess o. b. Admit to the hospital with specialist consultation p. c. Give epinephrine injections and monitor response q. d. Prescribe an oral corticosteroid medication 4 NUR 775 Unit 3 ANS: B Patients having an asthma exacerbation should be referred if they fail to improve after three nebulizer treatments or three epinephrine injections, have a peak flow less than 70% and a pulse oximetry reading less than 90% on room air. Giving more nebulizer treatments or administering epinephrine are not indicated. The patient will most likely be given IV corticosteroids; oral corticosteroids would be given if the patient is managed as an outpatient. REF: Definition and Epidemiology Chapter 105: Chronic Cough 6. 1. A young adult patient develops a cough persisting longer than 2 months. The provider orders pulmonary function tests and a chest radiograph, which are normal. The patient denies abdominal complaints. There are no signs of rhinitis or sinusitis and the patient does not take any medications. What will the provider evaluate next to help determine the cause of this cough? m. a. 24-hour esophageal pH monitoring n. b. Methacholine challenge test o. c. Sputum culture p. d. Tuberculosis testing ANS: B Chronic cough without other symptoms may indicate asthma. If PFTs are normal, a methacholine challenge test may be performed. 24-hour esophageal pH monitoring is sometimes performed to evaluate for GERD, but this patient does not have abdominal symptoms and this test is usually not performed because it is inconvenient. Sputum culture is not indicated. TB is less likely.REF: Diagnostics 4. 2. A patient is recovering from Mycoplasma pneumoniae infection and has a persistent cough 6 weeks after the infection. What will the provider do? q. a. Perform chest radiography to assess for secondary infection r. b. Perform pulmonary function and asthma challenge testing s. c. Prescribe a second round of azithromycin to treat the persistent infection t. d. Reassure the patient that this is common after M. pneumoniae infection ANS: D Post-infection cough is common after M. pneumoniae infection and may persist up to 8 weeks after the infection; this type of cough generally needs no intervention. It is not necessary to perform chest radiography unless secondary infection is suspected. Antibiotics are not indicated. Unless the cough persists after 8 weeks, asthma testing is not indicated.REF: Definition and Epidemiology