Nur 138 Final Exam Questions With Correct
Answers
What |is |included |in |a |physical |assessment |for |immunity?
Assess |lymph |nodes, |temperature, |mobility, |general |appearance, |skin, |history |of |infections, |
immunization |status
Define |artificial, |acquired |passive |immunity?
Given |antibodies |to |the |disease |rather |than |developing |them
Ex: |Immunoglobulins
Active |vs. |Passive |immunity
Active |is |honestly |earned; |long |term
- |Vaccines: |MMR
- |natural |infection
- |Develops |memory |B |cells |that |can |quickly |respond |to |future |exposure |to |the |antigen
Passive |is |donation; |short |term
- |no |memory |developed
- |Rabies |shot
- |Mom’s |breastmilk
- |Immunoglobulins |(Rhogam, |Covid)
- |Antivenom
- |Tetnus |toxoid
antibody |vs. |antigen
Antigen |(Ag) |(aka |Immunogen): |A |substance |that |causes |the |body |to |produce |an |immune |
response.
Antibody |(Ab): |Proteins |made |in |response |to |an |Ag; |can |combine |with |that |Ag.
LOW |WBC |(Nursing |Interventions)
,Neutropenic |precautions: |wear |a |mask, |be |careful |of |infections, |avoid |crowds
Report |any |temp |>100 |to |the |doctor
Avoid |crowds |and |sick |people
Avoid |yard |work/gardening
Don't |change |the |cat |littler |box
wash |dishes |in |hot |water |or |in |the |dishwasher. |Also |wash |their |toothbrush!
High |WBC |(nursing |interventions)
Infection |- |identify, |then |treat |the |infection
Care |of |client |after |exposure |to |allergen
Epipen, |then |go |to |the |ER
Keep |the |epipen |room |temperature, |keep |it |with |you, |make |sure |it's |at |room |temperature, |
train |all |the |people |around |you
Recognize |diagnostic |lab |changes |that |indicate |infection
> |High |WBC |(>10000)
> |Leukocytosis: |Increased |white |blood |cell |count, |indicating |the |body |is |fighting |an |infection.
> |Left |shift: |Increase |in |immature |white |blood |cells, |suggesting |a |more |severe |infection.
> |Elevated |C-reactive |protein |(CRP): |Marker |of |inflammation |in |the |body.
> |Elevated |erythrocyte |sedimentation |rate |(ESR): |Non-specific |marker |of |inflammation.
> |Positive |cultures: |Growth |of |bacteria |or |other |pathogens |in |a |sample |of |body |fluid.
Complications |of |NSAID |use |in |older |adults
> |GI |: |NSAIDs |can |irritate |the |stomach |lining |and |increase |the |risk |of |ulcers |and |bleeding.
> |Kidneys: |blood |urea |nitrogen, |creatinine. |NSAIDs |can |decrease |blood |flow |to |the |kidneys |
leading |to |a |decline |in |kidney |function. |This |risk |is |particularly |high |in |older |adults |who |may |
already |have |reduced |kidney |function.
> |Liver: |AST/ALT |elevated |liver |enzymes |NSAIDs |can |cause |a |temporary |increase |in |liver |
enzymes, |which |can |indicate |liver |damage.
> |Heart |attack |and |stroke: |risk |increased, |especially |in |high |doses |and |with |long-term |use.
Additional |considerations:
Dehydration: |Older |adults |are |more |susceptible |to |dehydration, |which |can |exacerbate |the |
risks |associated |with |NSAIDs. |Drinking |plenty |of |fluids |is |crucial.
,Polypharmacy: |Older |adults |often |take |multiple |medications, |which |can |increase |the |risk |of |
interactions |and |side |effects. |Careful |monitoring |and |coordination |of |medications |are |
essential.
Underlying |health |conditions: |Certain |underlying |health |conditions, |such |as |diabetes |and |
heart |disease, |can |put |older |adults |at |higher |risk |of |complications |from |NSAIDs.
Laboratory |monitoring: |Regular |monitoring |of |laboratory |tests |such |as |AST, |ALT, |blood |urea |
nitrogen, |creatinine, |and |electrolytes |is |crucial |for |detecting |early |signs |of |organ |damage |
associated |with |NSAID |use.
Indicators |of |a |Systemic |Reaction |to |Inflammation
Fever: |A |body |temperature |greater |than |100.4°F |(38°C) |is |a |common |indicator |of |
inflammation.
Increased |heart |rate: |The |heart |rate |typically |increases |in |response |to |inflammation, |as |the |
body |attempts |to |deliver |more |oxygen |and |nutrients |to |the |affected |area.
Edema |(swelling): |Inflammation |causes |fluid |build-up |in |tissues, |leading |to |swelling |in |the |
affected |area |or |throughout |the |body.
Decreased |urine |output: |When |the |body |is |fighting |inflammation, |it |may |retain |fluids, |leading |
to |a |decrease |in |urine |output. |This |can |be |a |serious |sign |of |impaired |kidney |function.
Respiratory |changes: |Rapid |breathing |or |shortness |of |breath |can |be |indicators |of |
inflammation |affecting |the |respiratory |system.
Altered |mental |status: |In |severe |cases, |inflammation |can |affect |the |brain, |leading |to |
confusion, |disorientation, |and |other |changes |in |mental |status.
Blood |tests: |Elevated |levels |of |certain |markers |in |the |blood, |such |as |C-reactive |protein |(CRP) |
and |white |blood |cell |count, |can |indicate |the |presence |of |inflammation |in |the |body.
Precautions |for |infection |control
Contact |isolation: |Used |for |infections |that |are |spread |through |direct |contact |with |an |infected |
person |or |their |body |fluids.
Standard |isolation: |Used |for |infections |that |are |spread |through |contact |with |an |infected |
person's |respiratory |secretions.
Airborne |isolation: |Used |for |infections |that |are |spread |through |the |air |when |an |infected |
person |coughs |or |sneezes.
, Protective |isolation: |Used |to |protect |a |person |with |a |weakened |immune |system |from |
infection.
Contact |precautions |and |diseases
Private |room |- |door |can |be |open
Gloves
Gown- |if |giving |direct |care
Handwashing
Disposable |supplies
Dedicated |equipment
MRSA, |C |Diff, |Scabies, |Multidrug-resistant |organisms |(MRDOs).
Droplet |precautions |and |common |diseases
Used |for |diseases |transmitted |via |respiratory |droplets |when |the |patient |coughs, |sneezes, |talks,
|or |breathes.
Flu, |Pertussis, |mumps, |COVID-19
Wear |a |mask, |maintain |3 |ft |of |separation, |proper |hand |hygiene, |patient |has |to |wear |a |mask |if |
leaving |the |room.
airborne |precautions |and |common |diseases
Used |for |diseases |that |can |be |transmitted |through |tiny |airborne |particles |that |remain |
suspended |in |the |air |for |an |extended |period.
TB, |measles, |chicken |pox, |disseminated |herpes |zoster
what |is |a |protective |environment |and |the |diseases |that |might |need |it?
Used |for |patients |with |compromised |immune |systems, |such |as |those |who |have |undergone |
bone |marrow |transplants |or |organ |transplants. |Or |who |have |cancer. |The |goal |is |to |protect |the |
patient |from |environmental |pathogens.
Maintain |strict |hand |hygiene, |use |sterile |techniques |when |handling |invasive |devices, |limit |
visitors |and |ensure |that |visitors |follow |infection |control |measures.
Nursing |Assessment |for |Infection
Take |the |client's |history
Assess |the |degree |of |risk |for |infection |through |observation |and |interview.
Physical |assessment |- |local |infection |= |warm, |redness, |swelling, |pain, |loss |of |function.
Systemic |infection |= |fever, |increased |pulse, |fatigue, |loss |of |appetite, |enlarged/tender |lymph |
nodes.
Answers
What |is |included |in |a |physical |assessment |for |immunity?
Assess |lymph |nodes, |temperature, |mobility, |general |appearance, |skin, |history |of |infections, |
immunization |status
Define |artificial, |acquired |passive |immunity?
Given |antibodies |to |the |disease |rather |than |developing |them
Ex: |Immunoglobulins
Active |vs. |Passive |immunity
Active |is |honestly |earned; |long |term
- |Vaccines: |MMR
- |natural |infection
- |Develops |memory |B |cells |that |can |quickly |respond |to |future |exposure |to |the |antigen
Passive |is |donation; |short |term
- |no |memory |developed
- |Rabies |shot
- |Mom’s |breastmilk
- |Immunoglobulins |(Rhogam, |Covid)
- |Antivenom
- |Tetnus |toxoid
antibody |vs. |antigen
Antigen |(Ag) |(aka |Immunogen): |A |substance |that |causes |the |body |to |produce |an |immune |
response.
Antibody |(Ab): |Proteins |made |in |response |to |an |Ag; |can |combine |with |that |Ag.
LOW |WBC |(Nursing |Interventions)
,Neutropenic |precautions: |wear |a |mask, |be |careful |of |infections, |avoid |crowds
Report |any |temp |>100 |to |the |doctor
Avoid |crowds |and |sick |people
Avoid |yard |work/gardening
Don't |change |the |cat |littler |box
wash |dishes |in |hot |water |or |in |the |dishwasher. |Also |wash |their |toothbrush!
High |WBC |(nursing |interventions)
Infection |- |identify, |then |treat |the |infection
Care |of |client |after |exposure |to |allergen
Epipen, |then |go |to |the |ER
Keep |the |epipen |room |temperature, |keep |it |with |you, |make |sure |it's |at |room |temperature, |
train |all |the |people |around |you
Recognize |diagnostic |lab |changes |that |indicate |infection
> |High |WBC |(>10000)
> |Leukocytosis: |Increased |white |blood |cell |count, |indicating |the |body |is |fighting |an |infection.
> |Left |shift: |Increase |in |immature |white |blood |cells, |suggesting |a |more |severe |infection.
> |Elevated |C-reactive |protein |(CRP): |Marker |of |inflammation |in |the |body.
> |Elevated |erythrocyte |sedimentation |rate |(ESR): |Non-specific |marker |of |inflammation.
> |Positive |cultures: |Growth |of |bacteria |or |other |pathogens |in |a |sample |of |body |fluid.
Complications |of |NSAID |use |in |older |adults
> |GI |: |NSAIDs |can |irritate |the |stomach |lining |and |increase |the |risk |of |ulcers |and |bleeding.
> |Kidneys: |blood |urea |nitrogen, |creatinine. |NSAIDs |can |decrease |blood |flow |to |the |kidneys |
leading |to |a |decline |in |kidney |function. |This |risk |is |particularly |high |in |older |adults |who |may |
already |have |reduced |kidney |function.
> |Liver: |AST/ALT |elevated |liver |enzymes |NSAIDs |can |cause |a |temporary |increase |in |liver |
enzymes, |which |can |indicate |liver |damage.
> |Heart |attack |and |stroke: |risk |increased, |especially |in |high |doses |and |with |long-term |use.
Additional |considerations:
Dehydration: |Older |adults |are |more |susceptible |to |dehydration, |which |can |exacerbate |the |
risks |associated |with |NSAIDs. |Drinking |plenty |of |fluids |is |crucial.
,Polypharmacy: |Older |adults |often |take |multiple |medications, |which |can |increase |the |risk |of |
interactions |and |side |effects. |Careful |monitoring |and |coordination |of |medications |are |
essential.
Underlying |health |conditions: |Certain |underlying |health |conditions, |such |as |diabetes |and |
heart |disease, |can |put |older |adults |at |higher |risk |of |complications |from |NSAIDs.
Laboratory |monitoring: |Regular |monitoring |of |laboratory |tests |such |as |AST, |ALT, |blood |urea |
nitrogen, |creatinine, |and |electrolytes |is |crucial |for |detecting |early |signs |of |organ |damage |
associated |with |NSAID |use.
Indicators |of |a |Systemic |Reaction |to |Inflammation
Fever: |A |body |temperature |greater |than |100.4°F |(38°C) |is |a |common |indicator |of |
inflammation.
Increased |heart |rate: |The |heart |rate |typically |increases |in |response |to |inflammation, |as |the |
body |attempts |to |deliver |more |oxygen |and |nutrients |to |the |affected |area.
Edema |(swelling): |Inflammation |causes |fluid |build-up |in |tissues, |leading |to |swelling |in |the |
affected |area |or |throughout |the |body.
Decreased |urine |output: |When |the |body |is |fighting |inflammation, |it |may |retain |fluids, |leading |
to |a |decrease |in |urine |output. |This |can |be |a |serious |sign |of |impaired |kidney |function.
Respiratory |changes: |Rapid |breathing |or |shortness |of |breath |can |be |indicators |of |
inflammation |affecting |the |respiratory |system.
Altered |mental |status: |In |severe |cases, |inflammation |can |affect |the |brain, |leading |to |
confusion, |disorientation, |and |other |changes |in |mental |status.
Blood |tests: |Elevated |levels |of |certain |markers |in |the |blood, |such |as |C-reactive |protein |(CRP) |
and |white |blood |cell |count, |can |indicate |the |presence |of |inflammation |in |the |body.
Precautions |for |infection |control
Contact |isolation: |Used |for |infections |that |are |spread |through |direct |contact |with |an |infected |
person |or |their |body |fluids.
Standard |isolation: |Used |for |infections |that |are |spread |through |contact |with |an |infected |
person's |respiratory |secretions.
Airborne |isolation: |Used |for |infections |that |are |spread |through |the |air |when |an |infected |
person |coughs |or |sneezes.
, Protective |isolation: |Used |to |protect |a |person |with |a |weakened |immune |system |from |
infection.
Contact |precautions |and |diseases
Private |room |- |door |can |be |open
Gloves
Gown- |if |giving |direct |care
Handwashing
Disposable |supplies
Dedicated |equipment
MRSA, |C |Diff, |Scabies, |Multidrug-resistant |organisms |(MRDOs).
Droplet |precautions |and |common |diseases
Used |for |diseases |transmitted |via |respiratory |droplets |when |the |patient |coughs, |sneezes, |talks,
|or |breathes.
Flu, |Pertussis, |mumps, |COVID-19
Wear |a |mask, |maintain |3 |ft |of |separation, |proper |hand |hygiene, |patient |has |to |wear |a |mask |if |
leaving |the |room.
airborne |precautions |and |common |diseases
Used |for |diseases |that |can |be |transmitted |through |tiny |airborne |particles |that |remain |
suspended |in |the |air |for |an |extended |period.
TB, |measles, |chicken |pox, |disseminated |herpes |zoster
what |is |a |protective |environment |and |the |diseases |that |might |need |it?
Used |for |patients |with |compromised |immune |systems, |such |as |those |who |have |undergone |
bone |marrow |transplants |or |organ |transplants. |Or |who |have |cancer. |The |goal |is |to |protect |the |
patient |from |environmental |pathogens.
Maintain |strict |hand |hygiene, |use |sterile |techniques |when |handling |invasive |devices, |limit |
visitors |and |ensure |that |visitors |follow |infection |control |measures.
Nursing |Assessment |for |Infection
Take |the |client's |history
Assess |the |degree |of |risk |for |infection |through |observation |and |interview.
Physical |assessment |- |local |infection |= |warm, |redness, |swelling, |pain, |loss |of |function.
Systemic |infection |= |fever, |increased |pulse, |fatigue, |loss |of |appetite, |enlarged/tender |lymph |
nodes.
