NRNP 6550 Midterm Exam Latest 162 Questions and Answers Latest Update 2024/2025

Vaccinations and immunosuppression. 2 keypoints - give inactive agents instead of live agents - might not work as effectively live virus vaccine types Virus: - measles - mumps - polio (oral) - rubella - varicella - yellow fever - herpes zoster Bacteria: - typhoid inactive vaccine virus Virus: - Hep A and B - HPV - influenza - polio (subq) - rabies Bacteria: - anthrax - cholera - diphteria - Lyme - meningococcus - pertussis - plague - pneumococcus - tetanus Immunization recommendation influenza all ages, all types (pregnant, diabetes, immunocompromised, etc) Immunization recommendation pregnancy and weakened immune system - 1 dose Tdap - no varicella, zoster, MMR HIV and vaccinations Give inactive agents when CD4 count is greater than 200 cells/ mm3 health screening 18 - 45 years - BMI - BP (q2years) - at age 20: fasting lipid profile: total cholesterol, LDL, HDL, triglycerides (cardiac testing if LDL greater than 200 or HDL lower than 40) - annual breast exam, females - Pap-smear annually health screening 45 and up - blood glucose q3years - 50 and up: colorectal screening (digital exam annually, sigmoidscopy q5years, colonoscopy q10yrs) - PSA with digital exam annually for males - mammography q1 -2 yrs - women 65 and up: screen for osteoporosis top 5 leading causes of death 1. heart disease 2. cancer 3. respiratory disease 4. stroke 5. accidents Conjunctivitis; definition -Pink eyey - Inflammation of conjuctiva (outer layer of eye) Conjunctivitis: causes Chemical, bacterial, viral, allergic, herpetic. Adenovirus is the most common cause, but bacteria (Haemophilus influenzae and Streptococcus pneumoniae) are also common causes in children. Conjunctivitis: findings - redness - itching - discharge - edema eyelid - may find gonorrhea or chlamydia in eye discharge Conjunctivitis: management - cooling - rule out corneal abrasion - bacteria: antibiotic solution (gentamicin, neomycin) - chlamydia: oral tetracycline or erythromycin - gonorrhea: single dose ceftriaxone - herpes: refer to opthalmologist Corneal abrasion: definition, cause, findings, treatment - disruption of cornea (clear covering of eye) - foreign body/ trauma - pain, redness, photophobia, decreased visual acuity - ab ointment: gentamicin, sulfacetamide, eye-patch, ophthalmologist diabetic retinopathy: definition, cause, findings, treatment - ocular retinal disease due to DM - DM, exac by smoking and HTN (macular edema) - flashing lights in vision, blurred vision, black spots, loss of vision, sustained glucose greater than 130 - Laser therapy for macular edema, smoking cessation, glucose control, BP control retinal detachment: definition, cause, findings, treatment - separation of retina and choroid - trauma, intraocular mass, iris inflammation, cataract surgery, DM, sickle cell - painless vision changes, blurred vision, light flashes, "curtain" over visual field, bullous elevation without tears - ophthalmologist for cryotherapy, laser therapy, vitrectomy. If from trauma: eye patch Central & Branch Retinal Artery Occlusion: definition, cause, findings, treatment - abrupt blockage of retinal artery causing sudden vision loss> will become permanent without intervention - thrombosis/ embolism, arteritis (migraine, older age, afib, DM, HTN, coagulopathies) - sudden, painless vision loss, sluggish pupil, cherry-red spot at fovea - EMERGENCY. Put pressure on eyelid, heparin, immediate consult opthalmolohgist. check coagulopathies, check labs for artherosclerotic disease, blood cultures (endocarditis?), Glaucoma: definition, cause, findings, treatment - progressive visual loss, first peripherally then centrally: chronic open angle or actute closed angle. Optic neuropathy. - open: too much intraocular fluid production without removal. Secondary from trauma, tumor, or cataracts. Causes: age, steroids, trauma, family history - Photophobia, visual blurring, unilateral headache. Increased intraocular pressure.Acute closed: eye pain and visual disturbance with N/V. - Acute: Emergency. immediate medication and surgery. Chronic: consult opthalmologist and monitor. Bimatropost, and beta-blockers. Laser-therapy Bell's Palsy: definition, cause, findings, treatment - sudden self-limited unilateral facial paralysis - Idiopathic. Cranial nerve VII (7), sometimes viral cause (herpes), HTN, DM, Lyme's - Unilateral paralysis of face (can't close eye, upper and lower face involved), herpetic lesions, taste disturbances - artificial tears, steroids (to treat CN 7 inflammation), antivirals otitis externa: definition, cause, findings, treatment - inflammation of the outer ear (swimmers ear) - water, fungi, bacterial, trauma, viral - pain with fullnes of ear, itching, edema, otorrhea - suction of debris, ab and steroid solution in ear, oral ab's (based on bld culture) otitis media: definition, cause, findings, treatment - inflammation of middle ear - congestion in eustachian tube, respiratory bacteria, neoplasm - pain, hearing loss, vertigo, nausea, pulsatile otorrhea, red and bulging tympanic membrane, hole in tympanic membrane with rupture - ab's (amoxi - 10 days), analgesic for pain, ENT for recurrent vertigo: definition, cause, findings, treatment - dizziness - vestibular neuronitis, meniere disease, damage to CN 8 (meningitis, trauma), damage to brain stem nuclei, syphilis, drugs, dm, TIA/ CVA - dizziness, tinitis, N/V, "full" ear, Romberg sign (sways/ falls with eyes closed) - TSH (to rule out hypothyroidism), CT/ MRI, glucose, treat symptoms/ bedrest, vestibular suppressants (meclizine, diazepam, scopalamine), antiemetics. low salt and diuretic with meniere epistaxis: definition, cause, findings, treatment - nosebleed - forceful expiration, winter, trauma, sinusitis, HTN, coagulopathies - bleeding from nose - head erect and elevated, cotton ball with Afrin, topical lidocaine, nasal packing sinusitis: definition, cause, findings, treatment - inflammation of the sinuses - upper respiratory infections, neoplasms - pain, headache, congestion - ab's (amoxi, doxycycl), analgesics pharyngitis: definition, cause, findings, treatment - inflammation of pharynx, often with tonsillitis - viral (influenza A & B, Adeno) (most common), bacterial (streptococcus), fungal - pain, fever. Viral: ulcers in oral cavity, edema of lymphoid tissue. Bacterial: white/ yellow exudate, swollen tonsils, bright red mucosa, high fever. Fungal: white spots - rapid strep test, throat culture, mono spot, chlamydia testing, pain relief. Strep: AB's (Bicillin, Cephalxein, azithromycin. Candida/ fungal: Nystatin, fluconazole Epiglottitis (Supraglottitis): definition, cause, findings, treatment - inflammation of mucous membrane resulting in airway obstruction because of swelling - bacterial (H. influenza, streptococcus, S. aureus) - voice change, dyspnea, anxiety, hoarse voice, drooling, don't examine pharync till x-ray done - xr-neck, CT neck, xr chest, CBC, bld cult, monitor vitals, ER, protect airway (nasotracheal intubation), ab's (3rd cephalo: ceftriaxone or vanco, or clinda) temporomandibular joint (TMJ) disorder: definition, cause, findings, treatment - pain in joint - rheumatoid arthritis, trauma, dentures, dental work - pain, jaw clicking, earache - NSAIDS, local heat, soft diet Trigeminal neuralgia (tic douloureux): definition, cause, findings, treatment - pain and pressure of CN 5 (face sensation and chewing) - idiopathic - intense sharp pain (unilateral) - CT (rule out neoplasm), MRI, carbamazepine, lamotrigine Labs and tests to perform for violent patient - blood/ urine drug screen - electrolytes - BMP - CT head Management of violent patients - summon police when weapons involved - calm voice - meds: Lorazepam (2mg), Olanzipine (5mg) Risperdal, Haldol (5mg) - restraints Depression findings - hopelessness, decreased appetite, lack of energy, suicidal thoughts, diarrhea/ impaction, abd. or chest pain Depression treatment Labs: TSH, vit B12, folate, glucose, CBC, ECG (before starting tricyclic antidepressants) Meds: take 6 - 8 wks to go into effect SSRI: citalopram, setraline, fluoxetine. Lower overdose or side effect potential.May add: effexor, cymbalta, buproprion or mirtazapine Tricyclic antidepressants and MAOI: overdose potential bipolar disorder, 3 types type 1: mania type 2: depressive type 3: fluctuating between mania and depression Bipolar treatment Lithium and depakote. Antidepressants can cause mania. Alcohol withdrawal treatment - rehydration - Thiamine - Hypoglycemia prevention - Benzodiazepines: diazepam and lorazepam Anxiety treatment - rule out physical cause - meds: - benzodiazepines: lorazepam - buspirone (slow onset of action: 2 wks) Delirium treatment - identify and address the underlying cause - optimize brain condition (O2, hydration, pain, etc. - antipsychotics: haldol (im), lorazepam and zyprexa (po) for dementia. Lorazepam may worsen delirium in elderly. SSRIs, which and side effects - Fluoxetine, paroxetine, sertraline, citalopram - takes 3 weeks to work - safer than other antidepressants - side effect: serotonin syndrome (shivering/ seizures) MAOIs, which and side effects - phenelzine - postural hypotension, weight gain, sexual dysfunction - avoid sauerkraut, wine, aged cheese, soy products: may cause hypertensive crisis tricyclic antidepressants, which and side effects - Amitriptyline, nortriptyline, imipramine, desipramine, clomipramine, doxepin, amoxapine - dry mouth, constipation, blurred vision, urinary retention, dizziness, tachycardia, delirium, orthostatic hypotension, weight gain, seizures, sexual dysfunction, arrhythmia Antidepressants and Bipolar Antidepressants and bipolar may cause mania Systole - contraction - AV valves (tricuspid and mitral) close, semilunar (aortic and pulmonic) valves open Diastole - filling - AV valves (tricuspid and mitral) open, semilunar (aortic and pulmonic) close Where do you hear aortic area of the heart second right intercostal space, right sternal border Where do you hear pulmonic area of the heart second left intercostal space Where do you hear Erb's point third intercostal space at left sternal border Where do you hear the tricuspid valve left lower sternal border at the fifth intercostal space Where do you hear the mitral valve fifth intercostal space midclavicular line S1 heart sound - closing of AV valves - R wave on ECG S2 heart sound - closing of semilunar valves - beginning of diastole Split S2 sound - heard on inspiration at pulmonic area (2nd left interspace at base) -occurs with every fourth beat -due to aortic valve closing faster than pulmonic valve S3 heart sound - Ventricular gallop - heard at apex (with bell of stethoscope), after S2 - caused by passive filling of noncompliant left ventricle - caused by HF, cardiomyopathy, fluid overload. Normal with pregnancy - Ken-tuc-ky S4 heart sound - atrial gallop - heard at apex (with bell), before S1 - atrial contraction filling noncompliant ventricle - caused by myocardial infarction, hypertension, left ventricular hypertrophy, heart failure - Ten-ne-see early diastolic murmur: sounds as, heard best at, means - decrescendo, high pitch - patient sits forward and holds breath - Aortic or pulmonic regurgitation (incompetent semilunar valves) diastolic rumbling murmur: sounds as, heard best at, means - sounds as: decrescendo - crescendo, low pitched - at apex - mitral stenosis and tricuspid stenosis (rheumatic heart disease) Midsystolic Ejection Murmurs: sounds as, heard best at, means - crescendo - decrescendo - aortic area - aortic or pulmonic stenosis Pansystolic Regurgitant Murmurs - blowing sound - apex - backward flow of blood. endocarditis midsystolic click mitral valve prolapse Aortic ejection click heard at apex, related to stenosis pulmonic ejection click heard at base friction rub: sounds as, related to, heard best at - scratchy - pericarditis - apex ECG Change with Hyperkalemia - Tall and peaked T waves - Prolonged PR Intervals - Widened QRS ECG Change with Hypokalemia - U waves (following t wave) - PVCs ECG change with hypercalcemia - AV block, BBB, bradycardia - shortened QT interval ECG change with hypocalcemia - bradycardia, ventricular ectopy, asystole - decreased cardiac output and hypotension ECG change hypomagnesemia - u wave - prolonged PR/ QT interval - widened QRS - flattened T wave - SVT - Torsades de pointes jugular vein distention A visual bulging of the jugular veins (greater than 5cm) in the neck that can be caused by fluid overload, pressure in the chest, cardiac tamponade, or tension pneumothorax. Risk factors CAD age, male, white, genes, smoking, HTN, DM, obesity, stress, oral contraceptives, HLD, elevaled LDL with low HDL Cholesterol screening Fasting lipid profile Start at age 20 years Every 5 years More aggressive for family history and obesity Total Cholesterol - ATP III <200 mg/dL desirable 200 - 239 borderline > 240 high Triglycerides - ATP III <150 mg/dL LDL - ATP III <100 optimal 100 - 129 near optimal 130 - 159 borderline 160 - 189 high <190 very high HDL low: <40mg/dl high: >60mg/dl Cholesterol goals for pt's with dm or CAD LDL less than 70 HDL greater than 40 TG less than 150 Management of high cholesterol - identify LDL, HDL, TGs (fasting lipid profile), clinical artherosclerotic disease, and risk factors for CHD Indications for statin therapy - clinical evidence of ASCVD, age <75 - LDL >190 - DM age 40-75 with LDL between 70 - 189 (moderate to high) - High intensity: adults >21 with LDL >190 - Moderate intensity: adults 40 - 75 with DM Statins: high/ moderate/ low dose - High: Atorvastatin 20-40mg or rosuvastatin 20 - 40mg. Lowers LDL by 50% - Moderate: Atorvastatin 10 - 20mg, Rosuvastatin 5 - 10mg, Simvastatin 20- 40mg. Lowers LDL by 30 - 50%. - Low: Simvastatin 10mg, Pravastatin 10-20mg. Lowers LDL by less than 30%. Side effects of statins - myopathy, hepatic dysfunction (monitor liver enzymes!), abd pain, rhabdo, n/v - many drug - drug interactions metabolic syndrome - 3 of these signs: abdominal obesity triglycerides > 150mg/dl HDL <40 (men), <50 (women) BP >130 syst or >85 diast fasting glucose >100 Treatment of metabolic syndrome Treat underlying causes Treat HTN Aspirin for pt's with CHD Treat elevated triglycerides or low HDL Treatment of elevated triglycerides - weight management, physical activity, avoid alcohol - treatment DM - reach LDL goal first. If still elevated triglycerides, then condider adding LDL lowering drug - if triglyceride level greater than 500mg/dl, avoid pancreatitis! By: low fat diet, weight management, start omega-3- fatty acids or niacin Risk factors for a myocardial infarction CAD HTN Metabolic syndrome obesity smoking DM 1 & 2 male family hx Time guidelines for STEMI Door to fibrinolytics: 30min Door to angioplasty: 90min Types of Angina Stable: intermittent pain (with exertion) lasting 1-5min, nitro may help, control with lifestyle changes and nitrates, beta-blockers, calcium channel blocker. St depression on ECG. Variant/ prinzmetal's: pain in rest (cor artery spasm so no atherosclerosis!) lasting up to 30min, manage with calcium channel blockers. ST elevation on ECG. Unstable: pain lasting longer than 30min, pain may radiate, nitrates do not relieve pain, manage with ACS protocol ECG changes for unstable angina, NSTEMI, and STEMI US and NSTEMI: ST depression. STEMI: ST elevation signs of MI progression: peaking of T waves, diminished R waves Ischemia: T wave inversion, peaked T waves, ST depression Injury: ST elevation greater than 1mm Infarction: Q waves greater than 25% of QRS complex Expected site of infarction based on ECG changes Inferior: leads II, III, AVF Inferolateral: II, III, AVF, V5, V6 Anterior: V3 and V4 Anteroseptal: V1, V2, V3 Posterior: V1 and V3 Right ventricular: V4R V6R Cardiac enzymes: which and timing troponin, increases after 4-6 hrs myoglobin, increases after 2-3 hrs CK-mb, increases after 4-8 hrs