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Term 4 (PN) > 176 final exam > Flashcards

176 final exam Flashcards

1
Q

What are the 6 elemants necessary for infections?

A
  1. infector agent (pathogen)
  2. reservoir (where pathogen grows)
  3. portal of exit (exit route from reservoir; entry route)
  4. mode of transportation (method of transportation)
  5. portal of entry (entrance through skin; entry route)
  6. Host
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2
Q

When would you want a patient with herpes zoster to take acyclovir?

A

Take within 72 hrs

14-28 days the symptoms would get better but not cure it

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3
Q

antihistamine - PO

Used for allergy symptoms & motion sickness

Side effects:
* Retention

Adverse reaction:
* Thrombocytopenia, hemolytic anemia

A

Diphenhydramine (Benadryl)

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4
Q

How do you know Vancomycin is working?

A

if diarrhea decreases

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5
Q

Antiretrovirals - PO/IV

Uses: genital herpes, shingles, HIV

adverse reaction:
* seizure
* hematuria
* AKF, SJS

Precautions: administer with food, increase fluid intake, and begin therapy with first onset of symptoms

A

Acyclovir (Zovirax)

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6
Q

Antifungal - PO/IV

Used for yeast infection

adverse reaction:
* seizure
* prolonged QT interval

A

Fluconazole (Diflucan)

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7
Q

Vasopressor - IM, SubQ, IV

used for acute asthmatic attacks, hemostasis, bronchospasm, anaphylaxis

side effects:
* tremors
* anxiety, tachycardia
* dizziness

adverse reaction:
* Dysrhythmias
* increased T wave

A

Epinephrine (adrenaline)

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8
Q

immunosuppressant - IV, IM PO

tx: RA, lupus and psoriasis

reactions:
- bone marrow suppression
- increased risk for infection
- DVT, AKI, liver failure
- decreased RBC
- leukocytopenia
- seizure, hepatotoxic

education:
- avoid large groups, people with infections
- receive inactivated vaccines (flu and pneumococcal)

A

Methotrexate (Rheumatrex)

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9
Q

NSAID used to treat mod- severe pain, inflammation, or arthritis
- RA, OA, tendonitis
- given PO, IV and recally

works if inflammation decreases

reactions:
- abnormal bleeding (hematuria)
- HF, AKI, HTN, MI, CVA
- liver failure, nephrotoxicity
- peripheral edema, cardiac changes
- N/V/D/C/A

BBW: CVA, MI & GI bleed risk

A

Indomethacin (Indocin)

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10
Q

Bronchodilator - PO

causes bronchodilation by action on B2 pulmonary receptors
- used for asthma

side effects:
- tremors
- anxiety, restlessness

A

albuterol

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11
Q

Antibiotic - PO/IV

Used against gram-positive, C-diff, streptococci, MRSA & staphylococci, & stomach infections

Nursing interventions:
* vital signs, check allergies
* monitor BUN/Cr levels (elevated levels not good)

Side effects:
* ototoxicity (check pt for hearing loss before given it, hearing aid)
* nephrotoxicity, n/v

Sever reaction: red man syndrome

A

Vancomycin (Vancocin)

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12
Q

What does ABCDE mean for melanoma?

A

A - asymmetry:
- one half not like the other/ uneven shape

B - border:
- irregular or poorly circumcised
- look for edges that are burned, notched, or ragged

C - color:
- varies from one area to another
- pigmentation is not uniform
- white/ blue are bad

D - diameter:
- larger than 6mm as a rule
- greater than the size of a typical pencil eraser

E - evolving:
- mole changes size, shape, color
- begins to bleed or scab points to danger

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13
Q

Most serious form of skin cancer
- deadly

cancerous neoplasm in which pigment cells invade the epidermis, dermis, and subq tissue
- can metastasize to any organ

characterized by black or dark brown patches on the skin that may appear uneven in texture, jagged, or raised

A

malignant melanoma

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14
Q

skin cancer that begin in the flat cells in the upper outer part of the epidermis but may grow into deeper tissue
- prone to metastasize

A firm nodular lesion topped w/ crust or a central area of ulceration

most common places:
- head, neck, and lower lip
- sites of chronic irritation & injury

A

squamous cell carcinoma (SCC)

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15
Q

You have a patient with a nut allergy . What would you educate this patient?

A

avoid peanuts in baked goods/ avoid all nuts in general

check food labels for nuts

wear medical bracelets

carry epi-pen

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16
Q

you are teaching a patient about safety precautions regarding cancer. what safety precautions would you suggest?

A

wear sunscreen
- no direct sunlight

self examinations and check moles frequently

wear sunglasses

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17
Q

Why do we use an EpiPen?

A

to help make RBC
- given subq

use for severe allergies

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18
Q

Tx for scabies - Topical

paralyzes and kills scabies and their eggs

side effects:
- itching
- mild rash
- headache

adverse reaction:
- severe burning
- stinging
- redness

A

Permethrin cream

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19
Q

A patient with AIDS has dark purplish brown lesions on the mucus membranes of the mouth. As the nurse you know these lesions correlate with what type of opportunistic disease?

A. Epstein-Barr Virus
B. Herpes Simplex Virus
C. Cytomegalovirus
D. Kaposi’s Sarcoma

A

D. Kaposi’s Sarcoma

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20
Q

Which HIV test can give the earliest test results?

A. Nucleic Acid Test (NAT)
B. Antibody HIV Test
C. Combination HIV antigen/antibody test
D. CD4 count

A

A. Nucleic Acid Test (NAT)

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21
Q

Human Immunodeficiency Virus (HIV) can NOT be spread in what type of fluid below? Select all that apply:

A. Breastmilk
B. Blood
C. Tears
D. Semen
E. Vaginal Fluid
F. Sweat

A

C. Tears
F. Sweat

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22
Q

What is the hallmark symptom of systemic lupus?

A

butterfly rash on face and chest

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23
Q

What do we do for a mom who has herpes and is going to deliver a baby?

A

c-section

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24
Q

T/F - Patients with herpes zoster are at risk for secondary infections

A

True

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25
Q

What would you do for a patient who is an IV drug user, prostitute, and has gonorrhea?

A

give her medication for gonorrhea and teach safe sex practices

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26
Q

You have a patient who is getting a blood transfusion and they are complaining about itching. what would be your priority?

A

stop the infusion

report to the HCP

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27
Q

You have a patient who is refusing a blood transfusion. What would your nursing priority be?

A

explain why they need the transfusion

assess why they are refusing

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28
Q

A patient has redness, swelling and warmth in the lower extremities. What would that indicate?

A

Cellulitis
- treat w/ antibiotics (penicillin)

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29
Q

You have a patient who is 6 months pregnant and has HIV, what would you teach this patient?

A

She cannot breast feed
- the baby can get the virus through the breast milk

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30
Q

You have a patient who is 5 years old and they have a bee sting. What symptoms would you anticipate seeing with a bee sting?

A

Swelling and hives

use epinephrine (epi-pen) or antihistamine

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31
Q

you are assessing a patient suspected of having scabies, what would you anticipate that looking like?

A

brown crust

Itchy lines on skin

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32
Q

You have a 5 year old patient and you are looking at the scalp. You notice nits in the hair. What would you anticipate the nits being?

A

lice

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33
Q

You have a patient who is having surgery and is allergic to latex. What information would you gather from the patient before surgery?

A

ask what type or reaction they have and notify the surgical team

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34
Q

You have a patient with HIV and you are educating them on multidrug therapy that is needed. What would you include in the education?

A

Take all medications that are prescribed and take at all times throughout the day

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35
Q

What kind of reaction is contact dermatitis?

A

skin reaction

new products cause this
- laundry detergent, dye and material

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36
Q

you have a patient who has a virtual infection. what medication would you anticipate giving?

A

Acyclovir

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37
Q

What kind of things are you concerned with regarding the skin during a physical assessment?

A

raised irregular edge moles

sore that healed

moles that are itchy

moles that is red w/ a black border

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38
Q

Dangerous infection of the blood
- caused by widespread infection

S/s:
- bounding pulse, tachycardia
- hypotension
- increases RR
- increased WBC’s & C-reactive protein (CRP)

Tx:
- treat cause
- fluid replacement
- vasopressors (norepinephrine & dopamine)

A

Sepsis

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39
Q

Most common and least severe type of skin cancer

often found on face and upper trunk
- might not be noticed by the patient

arise in the Basal cell layer of the epidermis
- scaly appearance
- pearly papule w/ central crate and waxy, pearly border

Tx: removal of area
- 40-50% recurrence

A

basal cell carcinoma

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40
Q

systemic/ chronic autoimmune disease in which the joints and some organs of the body systems are attacked
- wrists, knees, knuckles, fingers
- flares occur d/t stress
- causes chronic inflammation of synovial membrane

Balance exercise w/ rest

can affect anyone, but mostly women ages 30-60

believed to be caused by bacteria and viruses
- Ex: labor, infections

S/s:
- stiffness (in morning)
- joint pain, muscle weakness
- fatigue
- subq nodules

A

Rheumatoid arthritis (RA)

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41
Q

Body has adverse response to a blood transfusion
- allergic, febrile, hemolytic
- hypersensitivity disorder

can be mild, moderate, or severe

Stop the infusion and keep vein open (KVO)

follow protocol and ensure proper crossmatching and typing

store blood properly and administer w/in 4 hrs of removal from fridge

A

Transfusion reactions

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42
Q

Reaction to certain proteins in latex rubber

clients can develop an allergy to foods
- bananas, kiwis, and avocados

A

Latex allergy

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43
Q

Severe, acute, life-threatening response to an allergen in which the symptoms develop quickly
- fatal hypersensitivity
- usually given epinephrine

severe, sudden vasodilation from mast cells

three most important aspects:
- anaphylactic reaction
- antibody dependent
- delayed hypersensitivity

Tx:
- Epi (IV)
- Antihistamines
- Oxygen
- Resuscitation

A

Anaphylaxis

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44
Q

Why is it important to monitor the CD4 cell count?

A

The more significant the loss, the more severe the immunosuppression becomes

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45
Q

The end stage or terminal phase of HIV

CD4 < 200

A

acquired immune deficiency syndrome (AIDS)

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46
Q

The earliest infection phases of HIV is often referred to as…..

A

asymptomatic phase

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47
Q

Why is HIV/AIDS considered an immune system disorder?

A

immune system attacks the body making the body more susceptible to the disease infection

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48
Q

STD that attacks many parts of the body and is caused by a small bacterium called a spirochete
- bacterial infection that appears 2-14 days after exposure

S/s:
- ulcer
- spores
- discharge rash

can attack the brain, heart, eyes, liver, vessels and bones in a fetus

A

Syphilis

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49
Q

a sexually transmitted infection caused by herpes simplex virus 2

S/s:
- pain
- sores
- skin rash

A

genital herpes

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50
Q

A client is being admitted for the treatment of acute cellulitis of the thigh. The client asks the admitting nurse to explain what cellulitis means. The nurse bases the response on the understanding that the characteristics of cellulitis include:

A) An epidermal and lymphatic infection caused by Staphylococcus

B) An inflammation of the epidermis only

C) A skin infection into the subcutaneous tissue and dermis

D) An acute superficial infection of the lymphatics and dermis

A

D) An acute superficial infection of the lymphatics and dermis

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51
Q

A male client visits the physician’s office for treatment of a skin disorder. As a primary treatment, the nurse expects the physician to prescribed:

A) An IV corticosteroids
B) An IV antibiotic
C) An oral antibiotics
D) A topical agent

A

D) A topical agent

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52
Q

A female client with herpes zoster is prescribed acyclovir (Zovirax) 200mg PO q4h while awake. The nurse should inform the client that this drug may cause:

A) Palpitations
B) Dizziness
C) Diarrhea
D) Metallic taste

A

C) Diarrhea

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53
Q

How would you manage fungal infections?

A

Topical/ oral antifungals

antifungal soap

treatment lasts 2-6 weeks

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54
Q

superficial infection of skin & mucous membrane d/t fungus
- can spread by direct contact or inanimate objects

takes advantage of trauma in moist, warm tissue

risk factors:
- diabetes
- immunosuppressed
- pt taking antibiotics

3 types:
- tinea pedis (athletes foot)
- tinea corpon (ringworm)
- candidiasis (skin, mouth, vag, yeast infection)

A

Fungal infections

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55
Q

infection of the skin, mouth, or vagina caused by the yeast-type fungus Candida albicans

AKA “thrush”

Tx:
- Swish and swallow

A

Candidasis

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56
Q

fungal infection of the foot
- AKA “athlete’s foot”
- most common

S/s:
- skin maceration
- fissures and vesicles around/ below toes
- discoloration of infected area

Interventions:
- teach about foot care
- pay attention to areas surrounding the toes
- proper footwear to decrease swelling
- warm socks
- meds

A

tinea pedis

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57
Q

Ringworm of the body

S/s:
- flat lesions that are clear in the center with reddened borders & look like a raised circle
- round patches with elevated red borders of pustules
- papules / vesicles that affect the non hairy skin of the body

interventions:
- proper hand washing & body hygiene
- no sharing clothes
- wash sports equipment

A

tinea corporis

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58
Q

A fungal infection (ringworm) of the scalp

characterized by red papules, or spots, at the opening of the hair follicles

A

tinea capitis

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59
Q

Nurse Tamara discovers scabies when assessing a client who just has been transferred to the med-surgery unit from the day surgery unit. To prevent scabies infection from traveling to other clients, the nurse should:

A) Wash hands, apply a pediculicide to the clients scalp, and remove any observable mites

B) Isolated the clients bed linens until the client is no longer infectious

C) Notify the nurse in the day surgery unit of potential scabies outbreak

D) Place the client on enteric precautions

A

B) Isolated the clients bed linens until the client is no longer infectious

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60
Q

What population is at risk of getting Scabies?

A

overcrowded living conditions

poverty

world travel

anyone

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61
Q

Contagious skin disease transmitted by the human itch mite
- contact precaution

penetrates the skin and makes a burrow
- lays eggs that mature and rise to skin surface
- wrist, fingers, ect

transmitted by contact with the infected person

S/s:
- wavy, brown, threadlike lines (hands, genitals, body folds)
- Severe itching (can lead to infection d/t scratching; More common at night)

A

Scabies

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62
Q

What are some nursing interventions for pediculosis?

A

apply medication to rid the patient of lice

assess, identify, and treat everyone involved

encourage to clean furniture, carpet, linens, stuffed animals, ect

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63
Q

What are some ways you could treat pediculosis (lice)?

A

OTC prescription meds
- pyrethrin shampoo (RID)

Occlusive agents
- petroleum jelly

fine nit comb to get rid of eggs

Ages 2 and younger:
- peanut butter, mayo, ect

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64
Q

lice transmitted by close contact with infected individuals leaving eggs (nits) on skin/ hair surfaces

3 types:
- pediculosis capitis - head louse
- pediculosis corporis - body louse
- pediculosis pubis - pubic louse

lice live 1-2 days w/o blood source

A

pediculosis

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65
Q

The nurse prepared to care for a male client with acute Cellulitis of the lower leg. The nurse anticipates which of the following will be prescribed for the client?

A) Cold compress to affected area
B) Warm compress to affected area
C) intermittent heat lamp treatments 4x/day
D) alternating hot/cold compresses continuously

A

B) Warm compress to affected area

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66
Q

What are S/s of Cellulitis?

A

warm to touch

uneven swelling/ edema

redness on extremity

pain

drainage

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67
Q

diffuse, acute infection of the skin marked by local heat, redness, pain, and swelling

caused by a group of streptococci and staphylococcus aureus
- infection of skin cells
- more common in children
- Can become septic

involves the underlying tissue of the skin
- bacteria can spread to other open areas

not contagious

A

Cellulitis

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68
Q

The nurse manager is planning the clinical assignments for the day. which staff member can be assigned to care for a patient with herpes zoster (shingles)? SELECT ALL THAT APPLY

A) The nurse who never had german measles

B) the nurse who never received the varicella zoster vaccine

C) the nurse who never had mumps

D) the nurse who never had roseola

A

A) The nurse who never had german measles

C) the nurse who never had mumps

D) the nurse who never had roseola

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69
Q

The nurse is assigned to care for a female client with herpes zoster (shingles). Which of the following characteristics would the nurse expect to note when assessing the lesion of this infection?

A) clustered skin vesicles
B) A generalized body rash
C) small blue-white spots with a red base
D) cutaneous lesions on the hands, feet, and buttocks

A

A) clustered skin vesicles

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70
Q

How could you diagnose herpes zoster?

A

physical exam

a culture that isolates the virus

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71
Q

What are S/s of herpes zoster?

A

pain - precedes outbreak

rash - thoracic, lumbar, cervical regions, and cranial areas

vesicles erupt along the involved nerve tract

typically lasts 7-28 days

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72
Q

What are nursing interventions for Herpes Simplex Virus (HSV)?

A

Primary focus:
- treat the symptoms and prevent spread

keep lesions dry

loose fitting under clothing (HSV 2 outbreak)

education regarding transmission

73
Q

produces various types of vesicles that rupture and encrust, causing ulcerations
- initial outbreak most severe
- AKA “Genital Herpes”

flu like symptoms occur 3-4 days after vesicants rupture

most common sites are the cervix and penis
- present for 7-14 days

A

Herpes Simplex Virus (HSV) - Type 2

74
Q

Herpes Simplex Virus (HSV) Type 1 usually occurs after…

A

acute illness

infection

Takes 10-14 days to heal

75
Q

vesicle at the corner of the mouth, lips, or nose
- typically fluid filled
- AKA “Cold Sore”

S/s:
- fatigue
- pruritus and burning
- pain in mouth

can use OTC topical treatments

A

Herpes Simplex Virus (HSV) - Type 1

76
Q

The nurse plays a vital role in screening patients for a possible HIV infection. What questions below could the nurse ask to help identify a patient who is at risk for HIV? Select all that apply:

A. “How often do you use alcohol or drugs?”

B. “Have you recently experienced an abusive relationship?”

C. “If you are sexually active, do you or your partner use protection?”

D. “In the past month, have you felt sad or unable to get out of bed?”

E. “Have you ever been treated for a sexually transmitted infection?”

F. “Do you ever experience intrusive or unwanted thoughts?”

A

A. “How often do you use alcohol or drugs?”

C. “If you are sexually active, do you or your partner use protection?”

E. “Have you ever been treated for a sexually transmitted infection?”

77
Q

You’re providing education to a patient with AIDS on how to prevent opportunistic infections. Which statement below requires the nurse to re-educate the patient about this topic?

A. “I’m traveling to Puerto Rico next week and will be sure to pack bottled water.”
B. “I’ve switched to buying raw organic milk.”
C. “Last month I received the Pneumovax.”
D. “My neighbor bought a cat last week.”

A

B. “I’ve switched to buying raw organic milk.”

Patients with AIDS should AVOID raw, undercooked, and unpasteurized foods and beverages. These items could contain organisms that could cause serious infections to a person with a compromised immune system

78
Q

disease in which cancer cells are found in the skin or mucous membranes that line the gastrointestinal (GI) tract, from mouth to anus, including the stomach and intestines
- causes lesions to grow in the skin, lymph nodes, internal organs, and mucous membranes lining the mouth, nose, and throat

often affects people with immune deficiencies
- HIV or AIDS

Purple, red, or brown skin blotches are a common sign. Tumors also may develop in other areas of the body.

Treatment may include radiation or chemotherapy. Rarely, surgery may be needed

A

Kaposi’s Sarcoma

79
Q

A 48-year-old patient is HIV positive. The patient has no signs and symptoms and has a CD4 count of 400 cells/mm3. In addition, no opportunistic infections or diseases are present. These findings correlate with what stage of HIV?

A. Acute
B. Chronic
C. AIDS

A

B. Chronic

These findings correlate with the Chronic Stage (also called the Asymptomatic Stage) of HIV. Signs and symptoms may not be experienced, the viral load is lower than the Acute Stage, but the virus is still replicating and destroying the cells. The patient can still transmit the virus to others. In addition, the CD4 count should be more than 200 cells/mm3 to about 500 cells/mm3. In addition, no opportunistic infections or diseases should be present.

80
Q

What is a normal CD4 count?

A. 200-500 cells/mm3
B. 1500-3500 cells/mm3
C. 500-1500 cells/mm3
D. <200 cells/mm3

A

C. 500-1500 cells/mm3

81
Q

Identify the correct statements about the anatomy of the Human Immunodeficiency Virus (HIV). Select all that apply:

A. HIV is a retrovirus.

B. Inside the virus is packaged DNA.

C. The protein projections found on the virus’ surface play a key role in attaching to the receptors on the helper t-cell.

D. The glycoproteins (specifically GP140) are vital for engaging the receptors on the targeted cell.

A

A. HIV is a retrovirus.

C. The protein projections found on the virus’ surface play a key role in attaching to the receptors on the helper t-cell.

82
Q

Which statement below is not true regarding the role of the helper t cell?

A. The helper T cell releases cytokines to help activate other immune system cells.

B. The helper T cell is part of the adaptive immune system.

C. The helper T cell is cytotoxic and kills invaders.

D. The helper T cell has CD4 receptors found on its surface.

A

C. The helper T cell is cytotoxic and kills invaders.

All the other options are true statements about the helper T cell. Option C is NOT true. Helper T cells are not cytotoxic and kill invaders (this is another type of t cells called cytotoxic t cell). Helper T cells are “helpers” in that they HELP the immune system by releasing cytokines, which help activate other immune system cells

83
Q

The Human Immunodeficiency Virus (HIV) mainly attacks what type of cells in the human body?

A. Red Blood Cells
B. CD4 positive cells
C. Stem Cells
D. Platelets

A

B. CD4 positive cells

84
Q

cardiac glycoside
- therapeutic range: 0.5-2.0

helps heart contract, slows heart rate, increases cardiac output , decreases preload, fluid retention decreased

dont use on patients w/ renal disease

hold if apical pulse < 60 bpm

A

Digoxin (Lanoxin)

85
Q

You have a patient with RA. What interventions would you place?

A

rest between activities

ROM exercises

heating pads

anti-inflammatories, NSAIDS

86
Q

You have a patient with RA, you want them to go exercise class. What kind of things would you want them to do prior?

A

suggest warm bath or shower

87
Q

What would you teach a person who is newly diagnosed with herpes?

A

Safe sex practices
- can be transmitted through oral sex

stress management
- stress can bring on herpes

can lay dormant in the body for years

88
Q

What assessment would you do for a patient with an anaphylactic reaction?

A

maintain airway

administer epinephrine

89
Q

You are teaching a nurse methotrexate, what would you educate the nurse about this medication?

A

take blood pressure and pulse

used for ectopic pregnancies, eczema, RA, and crohn’s disease

90
Q

blood test to detect various antibodies in bloodstream such as HIV antibodies
- considered more precise than ELISA

A

Western blot test

91
Q

What is the enzyme-linked immunosorbent assay (ELISA) test used for?

A

To test the individuals blood for presence of antibodies to the HIV infection

92
Q

How would you treat malignant melanoma?

A

Skin graft

subsequent treatment modalities
- chemo
- radiation

nonspecific immunotherapy

93
Q

Anaphylaxis caused by hypersensitivity reaction is treated with…..

A

epinephrine, diphenhydramine, and steroids

94
Q

What medications would be given to a patient dx with lupus?

A

Methotrexate

NSAIDS

hydroxychloroquine

corticosteroids

95
Q

What can chlamydia cause?

A

infertility

96
Q

What are s/s of ICP?

A

Decreased level of consciousness:
* LOC
* lethargy to coma

Cushing’s triad:
* Severe hypertension
* Widened pulse pressure
* Bradycardia

Abnormal posturing:
* Decerebrate
* Decorticate

97
Q

Osmotic Diuretic
- inhibits reabsorption of water and electrolytes

Use: Cerebral edema, TBI, encephalitis

Adverse: Seizure, tachycardia, HF, Circulatory overload

Nursing Considerations:
- Check vitals ( for tachycardia)
- Monitor urine o/p (for dehydration)
- Monitor electrolytes (for electrolyte imbalance)
- BUN/Cr & liver panel
- May cause phlebitis at IV site
- Monitor neuro status
- Administer via a filter

Know it works when LOC, eye opening, urine o/p increase, & speech patterns all improve

A

Mannitol (Osmitrol)

98
Q

sudden, progresses rapidly, critical
- Lumbar puncture (consent needed)

Important relationship between BP, pulse, & ICP (cushing’s triad)

S/s:
- Headache, light sensitivity/ pupillary changes (early)
- Change LOC/speech/vision (early)
- Cushing’s triad, change in vitals (late)
- Motor/sensory, Flaccid (unable to move) (late)

Clinical management:
- Semi-fowlers/ 30 degrees, straight alignment, comfortable
- Suction 10 seconds, Ataxic / Biot’s Breathing (unpredictable irregularity)
- increase fluids to increase perfusion
- Mannitol, Decadron (MS)
- avoid flexion of the hips, waist, neck and rotation of the head, enemas and laxatives, and valsalva maneuver
- administer oxygen via NC

A

Increased Intracranial Pressure (IICP)

99
Q

What are some Dx tests for IICP?

A

MRI (tumors), CT (bleeding)

Skull X-ray (fractures, abnorm bone)

EEG (brain waves, seizures)

Brain biopsy (stages tumors)

lumbar puncture/ spinal tap (tests spinal fluid, infection/ diseases)

100
Q

Steroid - glucocorticoid - long acting

Decrease inflammation

use: Cerebral edema, allergic reaction, MS, meningitis

Side effect: Hypokalemia, hypotension

Adverse: HF, thrombocytopenia, angioedema

Monitor Bs, mood, & s/s of cushing’s syndrome, poor wound healing, liver panel, lipid levels, and cholesterol

A

Decadron (dexamethasone)

101
Q

chronic, progressive, degenerative neurological disorder
-cause is unknown (mostly genetic predisposition)

usually affect women ages 20-40

Myelin sheath damaged by immune system and nerve signal is disrupted (demyelination)

S/s:
- Blurred vision/ vision changes
- Tinnitus, decreased hearing
- urinary retention (Neurogenic incontinence, superpubic cath)
- Paralysis, muscle spams, weakness
- Speech/ swallowing issues (peg tube)

Dx based off Hx
- MRI of spinal cord and brain to reveal plaques that characterize
- No Cure

A

Multiple Sclerosis (MS)

102
Q

What are nursing interventions for MS?

A

Encourage mobility (ROM exercises, PT/OT)

increase fiber, fruit/veg, well balanced diet

avoid breakdown, reposition q2h

balance rest/ exercise, stress reduction

Control environment (avoid hot baths & monitor for urine retention)

protect from opportunistic diseases (C-diff, pneumonia)

Copaxone, Flomax, Baclofin

103
Q

“Brain attack” - medical emergency
- S/s appear suddenly
- occurs more in men

S/s:
- “worst headache ever” (Hemorrhagic)
- stiff neck (Hemorrhagic)
- loss of consciousness (Hemorrhagic)
- seizure (Hemorrhagic)
- depends on area affected (Ischemic)
- one sided weakness (unilateral; Ischemic)
- vision changes (Ischemic)
- confusion (Ischemic)
- headache (Ischemic)
- dysphagia (Ischemic)
​
2 types:
- Hemorrhagic: shows on CT
- Ischemic: does NOT show on CT

Tx:
- Monitor vitals, neuro assessment, and ask LKW

A

Stroke (CVA - Cerebrovascular Accident)

104
Q

What are some diagnostic tests for a stroke?

A

CT (fastest, determines stroke type)
-w/o contrast

MRI, ECG/EKG

EEG (later)

Cerebral & carotid angiography

Blood studies (lipid, PT/INR)

105
Q

Deficient blood flow to the brain from a partial or complete occlusion of an artery

Causes:
- Thrombotic (atherosclerosis; coagulation disorder/ chronic hypoxia)
- Embolic (thrombus is endocardial layer of heart; rheumatic heart disease)

treatment:
- Thrombolytics such as tissue plasminogen activator (tPA, alteplase; acute ischemic stroke)
- digests fibrin and fibrinogen and thus lyses the clot
- platelet inhibitors and anticoagulants given if stroke is caused by thrombus or embolus (ischemic stroke) to prevent more clots (must be given after 24hrs if treated with TPA)

A

Ischemic stroke

106
Q

Results from bleeding into the brain tissue or subarachnoid space
- the bleed causes damage by destroying and replacing brain tissue
- aneurysm is often the cause

treatment:
- craniotomy: clipping the aneurysm/ removing the clot to prevent re-bleed

A

hemorrhagic stroke

107
Q

Administered IV w/in 3hrs from onset stroke symptoms

breaks up clot causing stroke
- stronger than heparin

CT/MRI needed to confirm no hemorrhage exists in the brain

Bleeding precaution

A

Thrombolytic (t-pa)

108
Q

What are s/s of left sided brain damage?

A

slow/cautious behavior

speech problems, aphasia

Difficulty following verbal commands

Apraxia

difficulty performing simple tasks

right sided hemiplegia

109
Q

What are s/s of right sided brain damage?

A

Quick and impulsive behavior

Short attention span

Neglects left side

Easily distracted

left sided hemiplegia

110
Q

Infection of meninges, membrane around the brain and spinal cord, caused by a virus or bacteria

Vaccine given to prevent infection in people “living in crowds”
- travelers, military, dorms, ect

S/s (sudden; early recognition):
- fever, cold hands/feet,
- rash, pale, blotchy skin
- v/, headache, confusion/ changed LOC
- stiff neck (chin tuck), severe muscle pain
- light sensitivity

Dx tests:
- Lumbar puncture (determines is bacterial or viral)
- CT/MRI (brain swelling, shows affect area, assesses for complications)
- Throat culture (detects/ identifies bacteria

A

Meningitis

111
Q

What are two positive signs of meningitis?

A

Kernig’s sign
- resistance of leg while hip flexed 90 degrees then raise foot

Brudzinski sign
- Head to chest w/ knees flexed

112
Q

Most severe form of meningitis
- medical emergency

Can have seizure or neurological defects
- show s/s of swelling on brain

person to person contacts / contagious
- droplet isolation
- enters through nose & pharynx

Tx:
- Droplet isolation
- prompt recognition
- broad spectrum antibiotics

A

Bacterial meningitis

113
Q

Inflammation of the brain
- Usually viral - slower/ gradual onset
- resembles meningitis
- fatal if untreated

May be from HIV, ticks, mosquitoes, measles, pox or mumps
S/s:
- Neuro damage
- N/V/H/Fever
- Seizure, aphasia, paralysis
- stiff neck, muscle weakness
- Abd. pain
- Increased BP/ cushing’s triad

Tx:
- Safety precaution (increase seizure & fall risk)
- meds for comfort
- therapy to increase strength, speech & ADLs
- Monitor vitals & neuro status

A

Encephalitis

114
Q

Sudden change in behavior d/t electrical hyperactivity in the brain

can lead to permanent neuro damage d/t depletion of O2 & glucose stored in the brain

Causes:
- Trauma, infection, epilepsy
- reduced cerebral perfusion
- Electrolyte disturbance ( hypoglycemia, acidosis, dehydration, metabolic panel)
- tumors, stress, drugs
- genetic tendencies

Dx:
- Rule out specific problems (aura)
- EEG (detects brain wave activity)

4 types:
- focal, generalized, acute symptomatic seizure, & unprovoked seizure
Anticonvulsant drug therapy
- DONT STOP TAKING MEDS

A

Seizure

115
Q

Affects one area of the cortex affected during onset seizure
- most commonly occurs with epilepsy

Retained or impaired awareness
- may appear awake but usually do not respond to instructions or questions

Can tell when seizure is about to begin
- seizure typically lasts < 3 min
- Aura typically precedes the seizure

A

Focal Seizure

116
Q

Affects the whole brain
- most common
- Loss of consciousness

tonic clonic
- fall/ slumped, stiffness, jerking, frothing, cyanosis
- post-ictal stage
- injury risk
- about 1 min long

Myoclonic
- brief jerking/ stiffness

Absent
- “staring spells”
- eye blinking, lip smacking
- 5-10 seconds long

A

Generalized seizure

117
Q

Medical emergency d/t continuous seizure for over 30 min
- depletes O2 and glucose from the brain resulting in permanent brain damage

IV anticonvulsants, neuromuscular blocks or general anesthetics used to stop/ slow activity

Tx:
- resolve underlying cause
- dose of meds gradually increase until therapeutic level achieved
- Combination of anticonvulsants may be needed to help control activity
- DO NOT STOP TAKING (can lead to severe seizure activity)
- Ask when last seizure was

Management:
- safety precautions (do not leave client)
- padded side rails, side lying position
- move from harmful objects
- Remove loose fitting clothing, don’t restrain
- provide privacy, note time and duration
- provide education on stress, alc/caffeine, and meds (keppra, lorazepam, ect)
- if aura = find safe place

A

Status epilepticus

118
Q

Inhibits seizure activity (antiseizure) - IV
- reduces pain

Use: generalized tonic-clonic seizures; status epileptic

Side effects:
- Hypotension
- Slurred speech
- Agranulocytosis
- Skin rash
- N/V/Constipation

adverse reactions:
- V-fib, bradycardia, cardiac arrest
- hepatitis

Interventions:
- Monitor BP & HR (report bradycardia)
- safety precautions (if Ataxic or drowsy)

A

Dilantin (phenytoin)

119
Q

Antiseizure/anticonvulsant/mood stabilizer
- slows transmission of impulses in the CNS
- prevents seizure
- reduces pain

Use: tonic-clonic, complex-partial, mixed seizures

Side effects:
-Drowsy/ ataxia (lose muscle control)
- fluctuating BP
- HF, urine retention
- Rash, hepatitis
- Aplastic anemia (body stops producing new blood cells)
- Agranulocytosis
- Increased BUN

Adverse reaction:
- SJS

Interventions:
- Monitor BP
- Avoid Alc. and excessive sunlight
- Report fever, jaundice, bruising/ bleeding

A

Tegretol (carbamazepine)

120
Q

antiseizure/ antipsychotic
- PO/IV

used to decreases seizure activity
- simple, complex, absent seizures

Side effects:
- Lethargy/ dizziness
- Ataxia (lose muscle control)
- Thrombocytopenia
- N/V/H, weight gain
- Tumor, Alopecia

Interventions:
- Monitor Blood work
- Safety precaution (if drowsy)

A

depakote (valproic acid )

121
Q

Antiseizure/ Anticonvulsant - PO/IV
- stabilise electrical activity in the brain and prevent seizures
- Decreases severity and incidence of seizures

adverse reaction:
- hepatitis, SJS

Interventions:
- Safety precaution (if drowsy)
- Ask when last seizure was
- Interacts w/ other drugs
- No Alc.
- DO NOT STOP TAKING
- May alter RBC, WBC, and liver function

A

Keppra (levetiracetam)

122
Q

Antiseizure/ Sedative/ benzodiazepines - PO, IM, IV
- Initial tx of epilepsy

Side effects:
- Resp. depression
- Hypotension
- Phlebitis

adverse reaction:
- ECG changes
- Tachycardia
- Apnea
- Cardiac arrest (IV, rapid)

Interventions:
- Safety precaution (if drowsy)
- Monitor for extravasation
- Monitor BP

A

Ativan (Lorazepam)

123
Q

Antiseizure/ Sedative - IV
- can treat anxiety, muscle spasms, MS, CIWA and seizures

Side effects:
- Hypotension
- Blurred vision

Adverse reaction: Resp. depression

Interventions:
- Assess IV site
- Monitor vitals
- May go into alc./drug withdrawal

A

Diazepam (Valium)

124
Q

MS agent given subq

action: modifies immune responses responsible for MS by serving as a decoy to local antibodies

Side effects:
- n/v/d
- blurred vision
- tachycardia

adverse reactions:
- laryngospasms

A

Glatiramer acetate (Copaxone)

125
Q

Short term confusional state w/ sudden onset (reversible/ transient)
- disturbance in consciousness that impairs awareness of environment

Management:
- Treat cause
- infection give antibiotics, agitation give antipsychotics
- drug interaction = change med
- minimal stimulus
- family objects in room, keep same nursing staff (impaired cognition)
- Watch for electrolyte imbalance
- High BUN & Cr

Goals: Safety, comfort, decrease anxiety

A

Delirium

126
Q

What are factors that contribute to delirium?

A

Infections:
- meningitis, encephalitis, HIV, UTI
- Bacteremia, septicemia

Cardiovascular disease:
- Hypovolemia, CHF

Metabolic conditions:
- Fluid / electrolytes, DM
- Hepatic/renal/pulm, failure

Vascular incidents:
- Stroke, chronic subdural hematoma

Trauma:
- Head injury, burns, hip fracture

127
Q

The nurse is collecting data from a client, and the client’s spouse reports that the client is taking donepezil hydrochloride (Aricept). Which disorder should the nurse suspect that this client may have based on the use of this medication?

A. Dementia
B. Schizophrenia
C. Seizure disorder
D. Obsessive-compulsive disorder

A

A. Dementia

128
Q

Which of these clinical observations should the UAP report to the LPN for a client with a brain tumor who is taking dexamethasone?
(Select all that apply)

A. Weight gain of 3 lbs since yesterday

B. Tremors and diaphoretic skin

C. Blood pressure change from 150/90 to 120/78

D. Complaints of a sore throat

E. Moist cough

A

A. Weight gain of 3 lbs since yesterday

D. Complaints of a sore throat

E. Moist cough

129
Q

A student nurse was asked which of the following best describes dementia. Which of the following best describes the condition?

A. Memory loss occurring as part of the natural consequence of aging.

B. Difficulty coping with physical and psychological change.

C. Severe cognitive impairment that occurs rapidly.

D. Loss of cognitive abilities, impairing ability to perform activities of daily living.

A

D. Loss of cognitive abilities, impairing ability to perform activities of daily living.

130
Q

WHEN CARING FOR A PATIENT AFTER A HEAD INJURY, THE NURSE WOULD BE MOST CONCERNED WITH ASSESSMENT FINDINGS WHICH INCLUDE RESPIRATORY CHANGES ALONG WITH WHAT OTHER FINDINGS?

A. HYPERTENSION AND TACHYCARDIA

B. HYPOTENSION AND TACHYCARDIA

C. HYPOTENSION AND BRADYCARDIA

D. HYPERTENSION AND BRADYCARDIA

A

D. HYPERTENSION AND BRADYCARDIA

131
Q

Impaired ability to remember, think, or make decisions that interferes with doing everyday activities
- Not a part of normal aging
- Not a disease, but a clinical symptom

nursing interventions:
- Allow pt to perform what they can (impaired ADLs)

  • High protein foods (inadequate nutrition)
  • Keep awake during the day (sleep disturbances)
  • Safe environment (potential injury)
  • establish toilet schedule, or urinary intervention (urinary incontinence safety)
  • Agitation may mean pain, hunger, stress, fear, or toileting

3 types:
- Alzheimer’s Disease (most common)
- Vascular dementia
- Lewy Body Dementia

A

Dementia

132
Q

What are some dx associated with dementia?

A

TBI, subdural hematoma

Brain tumor

Neurosyphilis

AIDS

133
Q

Treats symptoms of Alzheimer’s disease, seizures, and Afib - PO
- Mild to severe

Helps improve your attention, memory and ability to complete your daily tasks

Contradictions: Does Not prevent/ slow neurodegeneration by AD

Adverse:
- Bradycardia

Nursing considerations:
- Notify HCP if HR < 60bpm

A

Donepezil (Aricept)

134
Q

Treats dementia associated w/ Alzheimer’s disease - PO
- Mod to Severe AD

Interventions:
- Monitor Ph of urine

A

Namenda (memantine)

135
Q

protein hormone synthesized in the pancreas that regulates blood sugar

Rotate injection site to prevent lipohypertrophy & lipoatrophy
- DO NOT massage
- Heat & exercise increase absorption rate

lowers blood glucose

AKA “beta cells”
- acts as key that allows sugar into the cell

A

Insulin

136
Q

Used when Blood sugar drops

AKA “alpha cells”

A

glucagon

137
Q

Elevated BS (>100)
- occurs in type 2 DM

Can result from:
- Insufficient insulin production / secretions
- Deficient hormone signaling
- Excessive counterregulatory hormone secretion

S/s: (Think “FLUSHED”)
- F: Flushed skin/ fruit like breath (acetone)
- L: Listless/ lethargic
- U: Unusual thirst, hunger,urine o/p (3 p’s)
- S: Skin warm/ dry, poor wound healing
- H: hyperventilation (kussmaul RR - deep/rapid breathing)
- E: Emesis, increased N/V ( late findings)
- D: Drowsiness, decreased appetite (N/V)

A

Hyperglycemia

138
Q

BS less than normal (<70)
- occurs in type 1 & 2

S/s:
- Tremors, tachycardia
- Clammy skin, cold
- Alt consciousness, irritability
- Hunger
- seizure/ stroke like s/s
- diaphoresis
- Apathy (severe lethargy)

Can result from:
- Insufficient intake
- Adverse reaction to meds
- Excessive exercise

A

Hypoglycemia

139
Q

What are some diagnostic testing for diabetes?

A

Glucose screening:
- Fasting, GTT, Glycosylated hemoglobin (HgbA1c; below 7%)

Antibody testing:
-Glutamic acid decarboxylase (GAD- T1), C-peptide

lipid analysis:
- Triglycerides, HDL, LDL

Renal function tests:
- BUN/Cr, albumin in urine,

C-reactive peptide

140
Q

DM dx test

level > 100 and < 126 is indicative of prediabetes of impaired fasting glucose

A level of 126 or higher on two separate occasions is indicative of diabetes

A random blood glucose measurement > 200 with s/s of diabetes is conclusive

A

Fasting glucose

141
Q

DM dx test

Most sensitive measure of glucose metabolism

Can often detect early Diabetes

A

Glucose Tolerance Test (GTT)

142
Q

DM dx test

Measures average blood glucose reading and estimates glucose control for the prior 3 months

A reading of 6.5% is indicative of diabetes

An A1c of 70% has been associated w/ reduced risk for complications of diabetes
- recommended goal for glucose control

A

Glycosylated hemoglobin (HgbA1c)

143
Q

Most common Antibody test for type 1 DM

A

Glutamic Acid Decarboxylase (GAD)

144
Q

Direct measure of insulin levels

CPT & fasting insulin may help determine quality of residual insulin prediction

A

C-peptide test

145
Q

Made by body during times of stress/ infection

elevated in people w/ DM and associated w/ the inflammatory of insulin

lab value: < 1.0 mg/L

A

C- reactive protein (CRP)

146
Q

List secondary preventions (screenings) used to detect complications in Diabetes:

A

A1C checked 2x/year

Annual renal function and lipid tests

Annual dental, foot, and eye exams

147
Q

Used for low blood sugar between 55-69 mg/dL

have 15 grams of carbs and check your blood sugar after 15 minutes

If it’s still below your target range, have another serving

Repeat these steps until it’s in your target range.

A

15x15x15 rule

148
Q

Chronic disorder characterized by impaired metabolism & vascular neurologic complications

Increase risk for heart disease, blindness, amputation, renal disease & pregnancy complications

Diet should be mix of carbs, proteins
& fats

Complex carbs prefered:
- Fruit/veg, wheat bread, ect

Check Bs before & after exercise
- DO NOT exercise during insulin peak (increases risk for hypoglycemia)
- Aerobic: Running, walking, swimming, biking
- Anaerobic: Weight lifting, yoga, ect

A

Diabetes

149
Q

Insulin produced by own body

Type 2: inadequate endogenous insulin & the bodies inability to use insulin correctly

A

Endogenous insulin

150
Q

Insulin obtained from other sources
- brings sugar into the body

Type 1: absence of endogenous insulin

A

Exogenous Insulin

151
Q

Autoimmune process possibly triggered by viral infection, destroys beta cells (insulin)
- if sick, check BS q2-3hr, give insulin as scheduled & check urine (BS >200 breaks down ketones)

Affected people need exogenous insulin for life

Goal: Have controlled Bs
- BS 120-140 depending on person

S/s:
- Polyuria (dehydration/ hypovolemic shock)
- Polyphagia (no glucose for cell energy)
- polydipsia (d/t diuretics)
- Weight loss (10lb/week)
- weakness/fatigue
- Hyperglycemia/DKA

A

Type 1 DM

152
Q

How do you manage Type 1 DM?

A

Med therapy:
- IV insulin drip (regular/short)

Nutrition therapy:
- Monitor calories & weight

Check BS before exercise

Manage stress/ acute illness
- increased BS d/t cortisone (counter reg. hormone)

Snack in middle of day and before bed to prevent BS from decreasing at night

153
Q

Lispro (Humalog)
Aspart (Novolog)

Clear insulin; most common

Given before pt eats

Onset: 10-30 minutes
Peak: 2hrs
Duration 3-5hrs

A

Rapid insulin

154
Q

Humulin R
Novolin R

Clear

Only insulin able to be administered by IV
- Takes longer to kick in

Onset: 30min-1hr
Peak: 2-3hrs
Duration: 5-8hrs

A

Short/ Regular insulin

155
Q

Humilin N
Novolin N

Cloudy; roll to mix

Onset: 2-4hrs
Peak: 4-12hrs
Duration: 12-16hrs

A

Intermediate Insulin/ NPH

156
Q

Glargine (lantus) - give seperatly
Detemir (levemir)

Clear; given in AM/PM

Onset: 1hr
Peak: N/A
Duration: up to 24hrs

A

Long acting insulin

157
Q

What is the difference between Lipohypertrophy & Lipoatrophy?

A

Lipohypertrophy: Lumps/swelling under skin at insulin injection site

Lipoatrophy: Hollow/ pitting of subq tissue at insulin injection site

158
Q

oral hypoglycemic that reduces hepatic glucose production and lowers fasting blood glucose levels
- initial treatment for T2DM

Does not cause hypoglycemia when used alone but increased risk when used with sulfonylurea d/t increase in insulin

Adverse reaction: Lactic acids

monitor for hypoglycemic reactions, renal studies, & CBC

BLACK BOX WARNING- Do not give w/ radiologic contrast (can lead to kidney failure & Lactic acids)
- HOLD MED 48hrs after contrast

A

Metformin (Glucophage)

159
Q

oral hypoglycemic that stimulates the pancreas to secrete insulin lowering blood sugar by causing the release of your body’s natural insulin
- Piggy backed w/ metformin (increases risk of hypoglycemia)

Adverse reaction:
- Hepatotoxicity
- Jaundice
- Hypoglycemia

Assess for hyper/hypoglycemic reactions & monitor vitals

Can increase liver function and kidney function labs

A

Glipizide (Glucotrol XL)
- Class: sulfonylurea

160
Q

oral hypoglycemic that assists the body to remove excessive glucose
- Decreases kidneys absorption of glucose, which promotes increase of glucose excretion in urine

Frequent urination, dizziness, or lightheadedness may occur
- get up slowly when rising from a sitting or lying position

Adverse reaction:
- signs of kidney problems
- Hyperkalemia
- increased LDL
- hypoglycemia

Monitor for DKA and Renal impairment

A

Empagliflozin (jardiance)
- Class: SGLT-2

161
Q

oral hypoglycemic that works to lower blood sugar, helping the pancreas make more insulin, decreasing the amount of sugar
- Slows gastric emptying
​
Improves blood sugar levels and lowers the risk of major cardiovascular events for adults with type 2 diabetes with heart disease
- stroke, heart attack or death

Does NOT replace the need for insulin
​
Adverse reactions:
- pancreatitis/ severe abd pain
- Thyroid cancer
- Renal damage/ Jaundice
- Hypoglycemia
- Allergic reaction
​
Assess skin, renal studies & Bs

A

Semaglutide (Ozempic)

162
Q

oral hypoglycemic that stimulates the pancreas to release insulin
- improves glucose homeostasis

DO NOT take if on insulin

adverse reaction:
- Acute renal failure
- UTI
- Pancreatitis (rare)
- Anaphylaxis
- increased liver enzymes

A

Sitagliptin (Januvia)
- Class: DPP-4

163
Q

Individuals w/ impaired fasting glucose (Bs 100-126), impaired GTT or both

need to receive education on weight reduction and increase physical activity

Testing should begin at age 45 or sooner if symptoms appear

A

Prediabetes

164
Q

anticoagulant found in blood and tissue cells
- IV

action:
- prevents conversion of fibrinogen to fibrin & prothrombin to thrombin (prevents clots)

use:
- prevention of treatment of DVT, PE,MI, and open heart surgery

adverse reaction: (bleeding)
- hematuria, hemorrhage

A

Heparin

165
Q

Anticoagulant (blood thinner)
- PO
- vitamin K antidote

action:
- interferes with blood clotting

adverse effects:
- hematuria and hemorrhage

BBW: monitor for bleeding

A

Warfarin (Coumadin)

166
Q

A hospitalized Patient is prescribed steroid medications (Prednisone) to treat their acute illness. This patient is NOT diabetic. Why is the patient prescribed insulin for elevated blood glucose levels?

A

The steroid raises Bs. The insulin is given to lower the Bs

167
Q

What is the treatment for a patient who is nonresponsive, cool & clammy to touch, and a blood glucose level of 34?

A

Glucagon

168
Q

NCLEX QUESTION

Insulin Glargine, is prescribed for a client with DM. The nurse tells the client that which is the best time to take the insulin?

A.) 1 hr after each meal

B.) Once daily at same time each day

C.) 15 min before breakfast, lunch, and dinner

D.) Before each meal on the basis of the blood glucose level

A

B.) Once daily at same time each day

169
Q

Which term is used to describe speech impaired to the point that the person has almost no ability to communicate?

A.) Global aphasia
B.) Expressive aphasia
C.) Receptive aphasia
D.) Nonfluent aphasia

A

A.) Global aphasia

170
Q

The nurse educates a client with diabetes on proper use of insulin glargine. The nurse determines further education is needed after which client statement?

A.) “I will rotate injection sites on my abdomen.”

B.) “I will use a sliding scale to determine my dose.”

C.) “I will throw out an opened vial after 28 days.”

D.) “I will keep my opened pen at room temperature.”

A

B.) “I will use a sliding scale to determine my dose.”

Explanation: Sliding scale doses of insulin are for short- or rapid-acting insulins only.Long-acting insulins like glargine are not dosed using a sliding scale

171
Q

The nurse triages a client with a history of type 1 diabetes who reports abdominal pain, nausea, weakness, and thirst. Fruity odor on the client’s breath is noted. A bedside glucose check shows the client’s blood sugar is 323 mg/dL (17.9 mmol/L). The nurse prepares for which drug therapy?

A.) Insulin detemir

B.) Insulin degludec

C.) Regular insulin

A

C.) Regular insulin

172
Q

The nurse receives a call from a client with type 2 diabetes. The client reports mid-morning blood sugars in the 60s for the last three days. Which oral antidiabetic medication is most likely causing this reaction?

A.) Sitagliptin phosphate, 100 mg, once per day

B.) Metformin, 1,000 mg, twice per day with meals

C.) Glipizide, 10 mg, daily 30 minutes before breakfast

A

C.) Glipizide, 10 mg, daily 30 minutes before breakfast
​
Explanation: Glipizide is a sulfonylurea oral antidiabetic medication that works by stimulating insulin release from the pancreas, reducing glucose produced by the liver, and increasing insulin sensitivity

173
Q

The nurse cares for clients in a major stroke center emergency department. Which client with suspected ischemic stroke is a likely candidate for alteplase?

A.) The client is currently experiencing heavy menstruation

B.) The client presenting to the hospital five hours after symptom onset

C.) The client with a blood pressure reading of 205/112 mm Hg

D.) The client presenting following a serious motor vehicle accident

A

A.) The client is currently experiencing heavy menstruation

Explanation: There is no contraindication for alteplase therapy in women experiencing menstruation.

174
Q

A client with diabetes type 1 is admitted to the emergency room with COVID-19-like symptoms. Which symptoms should the nurse report immediately?
Select all that apply.

A.) Blood glucose of 475 mg/dL
B.) Coughing and temperature of 99.8 F
C.) Deep rapid breathing
D.) Abdominal cramping
E.) ABGs with pH of 7.45

A

A.) Blood glucose of 475 mg/dL
C.) Deep rapid breathing
D.) Abdominal cramping

175
Q

A patient has impaired glucose tolerance, high serum insulin hypertension elevated triglycerides low high density cholesterol and altered size and density of low density lipoproteins (LDL) cholesterol’s. Which disorder is associated with these characters?

A.) Retinopathy
B.) Neuropathy
C.) metabolic syndrome
D.) macrovascular syndrome

A

C.) metabolic syndrome

176
Q

Life threatening emergency caused by insulin deficiency (acute onset: 4-10hrs)
- More common in T1DM but also seen in T2DM

Results in metabolism disorder of carbs, fats, & protein
- pt in state of metabolic acidosis

S/s:
- Kussmaul RR ( deep/rapid breathing)
- “Fruity” breath, polyuria
- Hypotension
- Hyperkalemia

Tx:
- IV fluids (Hydration; isotonic solution first)
- IV insulin drip until metabolic acidosis is corrected (regular/short acting)
- Electrolyte replacement
- Check Anion gap

A

DKA

177
Q

How will labs look during DKA?

A

Blood Glucose: 300-500

Ketone +

Decreased Na, & increased K

Increased Anion gap

Ph: < 7.3 or lower
CO2: decreased
HCO3: < 15 or lower

178
Q

Bs > 600 w/ no ketones

Occurs in T2DM d/t illness, infection, or being older age

Lack of insulin or inability to use available insulin can cause osmotic diuresis

Development of dehydration & hypernatremia

S/s:
- High sugar
- Increase fluid loss/ extreme dehydration
- Change in LOC, Confusion
- No ketones, no acid
- Slower onset & stable Potassium

Tx:
- Hydrate (isotonic solution then hypotonic)
- Stabilize sugars (IV insulin; short/ rapid)
- IV bolus, titration
- SubQ injection

A

Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)

Term 4 (PN) (8 decks)

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