NUR 265 Exam 4 ACTUAL Exam Questions
and CORRECT Answers
Lupus: Hallmark sign - CORRECT ANSWER - butterfly rash on face
Lupus: Indication of flare - CORRECT ANSWER - Fever and fatigue
*also assess BUN function
*c reactive protein remains normal
Lupus: Interventions - CORRECT 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 - CORRECT ANSWER - -hydroxychloroquine(anti-
malarial) decreases absorption of UV light
Scleroderma - CORRECT ANSWER - inflammatory, autoimmune connective tissue
disease
Scleroderma: Hallmark Sign - CORRECT ANSWER - Hard, leather-like edematous skin
Late: esophageal dismotility
Scleroderma: Assess - CORRECT ANSWER - Swallow safety--esophageal dysmotility
(ASPIRATION)
O2
,circulation
skin
Scleroderma: Interventions - CORRECT ANSWER - aspiration precautions (keep HOB at
60 degrees during meals and after)
skin protection measures
small frequent meals--avoid caffeine and alcohol
-avoid spices, caffeine and pepper
fibromyalgia: S/sx - CORRECT ANSWER - extreme fatigure
GI symptoms
dysuria
blurred vision
forgetfulness
fibromyalgia: Assess - CORRECT ANSWER - pain level
extreme fatigue
GI symptoms
Fibromyalgia: Interventions - CORRECT 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 - CORRECT ANSWER - stage 1: "bulls eye rash" and flu-
like symptoms
, Stage 2: facial paralysis, carditis, meningitis
Lyme Disease: Assess - CORRECT ANSWER - Skin
history of tick bites
Lyme Disease: Interventions - CORRECT ANSWER - 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 - CORRECT ANSWER - STOP THE INFUSION/ELIMINATE
the trigger, then STOP the immune response
Give Epi
maintain airway
Latex allergy: risks - CORRECT ANSWER - -frequent use of latex condoms
-healthcare workers
-allergy to avocados, bananas, and some nuts
Anaphylactic shock - CORRECT ANSWER - AIRWAY--give epi IV or IM STAT and
intubate if needed
BREATHING--apply O2; mechanically ventilate
CIRCULATION--monitor for distributive shock; give fluids
and CORRECT Answers
Lupus: Hallmark sign - CORRECT ANSWER - butterfly rash on face
Lupus: Indication of flare - CORRECT ANSWER - Fever and fatigue
*also assess BUN function
*c reactive protein remains normal
Lupus: Interventions - CORRECT 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 - CORRECT ANSWER - -hydroxychloroquine(anti-
malarial) decreases absorption of UV light
Scleroderma - CORRECT ANSWER - inflammatory, autoimmune connective tissue
disease
Scleroderma: Hallmark Sign - CORRECT ANSWER - Hard, leather-like edematous skin
Late: esophageal dismotility
Scleroderma: Assess - CORRECT ANSWER - Swallow safety--esophageal dysmotility
(ASPIRATION)
O2
,circulation
skin
Scleroderma: Interventions - CORRECT ANSWER - aspiration precautions (keep HOB at
60 degrees during meals and after)
skin protection measures
small frequent meals--avoid caffeine and alcohol
-avoid spices, caffeine and pepper
fibromyalgia: S/sx - CORRECT ANSWER - extreme fatigure
GI symptoms
dysuria
blurred vision
forgetfulness
fibromyalgia: Assess - CORRECT ANSWER - pain level
extreme fatigue
GI symptoms
Fibromyalgia: Interventions - CORRECT 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 - CORRECT ANSWER - stage 1: "bulls eye rash" and flu-
like symptoms
, Stage 2: facial paralysis, carditis, meningitis
Lyme Disease: Assess - CORRECT ANSWER - Skin
history of tick bites
Lyme Disease: Interventions - CORRECT ANSWER - 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 - CORRECT ANSWER - STOP THE INFUSION/ELIMINATE
the trigger, then STOP the immune response
Give Epi
maintain airway
Latex allergy: risks - CORRECT ANSWER - -frequent use of latex condoms
-healthcare workers
-allergy to avocados, bananas, and some nuts
Anaphylactic shock - CORRECT ANSWER - AIRWAY--give epi IV or IM STAT and
intubate if needed
BREATHING--apply O2; mechanically ventilate
CIRCULATION--monitor for distributive shock; give fluids
