NUR 265 EXAM 4 with correct answers

NUR 265 EXAM 4 with correct answers |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\




Lupus: Hallmark sign - correct answer✔✔butterfly rash on face
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Lupus: Indication of flare - correct answer✔✔Fever and fatigue
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*also assess BUN function
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*c reactive protein remains normal
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Lupus: Interventions - correct answer✔✔-Falls precautions
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-treat pain with tylenol and NSAIDS (monitor kidney function)
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-AVOID SUNLIGHT |||\\\




-REPORT FLARE IMMEDIATELY |||\\\ |||\\\




-clean skin with mild soap and pat dry and apply lotion
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Lupus: medical management - correct answer✔✔-hydroxychloroquine(anti-malarial) decreases
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absorption of UV light
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Scleroderma - correct answer✔✔inflammatory, autoimmune connective tissue disease |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\




Scleroderma: Hallmark Sign - correct answer✔✔Hard, leather-like edematous skin |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\




Late: esophageal dismotility
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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
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small frequent meals--avoid caffeine and alcohol
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-avoid spices, caffeine and pepper |||\\\ |||\\\ |||\\\ |||\\\




fibromyalgia: S/sx - correct answer✔✔extreme fatigure |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\




GI symptoms
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dysuria

blurred vision |||\\\




forgetfulness



fibromyalgia: Assess - correct answer✔✔pain level |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\




extreme fatigue |||\\\




GI symptoms
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Fibromyalgia: Interventions - correct answer✔✔NSAIDS |||\\\ |||\\\ |||\\\ |||\\\ |||\\\




Nuerontin (gabapentin) |||\\\




Lyrica (pregabalin) |||\\\




SNRI and tricyclic antidepressants (amitriptyline)
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promote sleep and low impact exercise (stretching, walking, swimming, rowing, water exercise)
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, Lyme Disease: Hallmark sign - correct answer✔✔stage 1: "bulls eye rash" and flu-like
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symptoms |||\\\




Stage 2: facial paralysis, carditis, meningitis
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Lyme Disease: Assess - correct answer✔✔Skin
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history of tick bites |||\\\ |||\\\ |||\\\




Lyme Disease: Interventions - correct answer✔✔prevention!
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Insect repellant with DEET |||\\\ |||\\\ |||\\\




early stage--doxycycline antibiotics ORAL
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late stage--Iv antibiotics (ceftriaxone)
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avoid tall grass |||\\\ |||\\\




wear light colored clothing
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have pets wear tick collars
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Allergic Reaction Priority - correct answer✔✔STOP THE INFUSION/ELIMINATE the trigger, then
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STOP the immune response|||\\\ |||\\\ |||\\\




Give Epi |||\\\ |||\\\




maintain airway |||\\\




Latex allergy: risks - correct answer✔✔-frequent use of latex condoms
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-healthcare workers |||\\\




-allergy to avocados, bananas, and some nuts |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\




Anaphylactic shock - correct answer✔✔AIRWAY--give epi IV or IM STAT and intubate if needed |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\