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NUR 265 Exam 4 # 183 Questions & Answers: Latest Updated: A+ Score Guide
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NUR 265 Exam 4 # 183 Questions & Answers: Latest Updated: A+ Score Guide
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NUR 265 Exam 4 # 183 Questions &Answers: Latest Updated: A+ Score
Guide
Lupus: Hallmark sign - -butterfly rash on face
-Lupus: Indication of flare - -Fever and fatigue
*also assess BUN function
*c reactive protein remains normal
-Lupus: Interventions - --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 - --hydroxychloroquine(anti-
malarial) decreases absorption of UV light
-Scleroderma - -inflammatory, autoimmune connective tissue
disease
-Scleroderma: Hallmark Sign - -Hard, leather-like edematous
skin
Late: esophageal dismotility
-Scleroderma: Assess - -Swallow safety--esophageal dysmotility
(ASPIRATION)
O2
circulation
skin
-Scleroderma: Interventions - -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 - -extreme fatigure
GI symptoms
dysuria
blurred vision
forgetfulness
-fibromyalgia: Assess - -pain level
extreme fatigue
GI symptoms
-Fibromyalgia: Interventions - -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 - -stage 1: "bulls eye rash" and
flu-like symptoms
Stage 2: facial paralysis, carditis, meningitis
-Lyme Disease: Assess - -Skin
history of tick bites
-Lyme Disease: Interventions - -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 - -STOP THE INFUSION/ELIMINATE
the trigger, then STOP the immune response
Give Epi
, maintain airway
-Latex allergy: risks - --frequent use of latex condoms
-healthcare workers
-allergy to avocados, bananas, and some nuts
-Anaphylactic shock - -AIRWAY--give epi IV or IM STAT and
intubate if needed
BREATHING--apply O2; mechanically ventilate
CIRCULATION--monitor for distributive shock; give fluids
-Epinephrine Auto-injector teaching - -always carry 2 devices
inject by "stabbing" into top of thigh with pants on (AVOID
pockets)
call 911 immediately--patient still needs to be monitored
keep epi in cool dark place.
-Immunocompromised Patient - --Do not drink anything that has
been sitting out
-take temp at least once per day
-clean toothbrush once weekly in diswasher or bleach solution
-do not eat raw foods; salad, cottage cheese
-do not scoop litter boxes
-no plants or soil exposure
-antibacterial soap
-AVOID reptiles
-HIV: Assess - -CD4 count
ELISA test once per year for at risk patients
-HIV: Interventions - -PREVENTION:
-condoms
-PreP (truvada) must take 4 consecutive days in a row before
protected; cant miss more than one dose in a row
-needle safety
-post exposure prophylaxis-start cART within 24-36 hours of
exposure
-HIV: Nutrition - -high calorie
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