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NUR 308 EXAM 2 STUDY QUESTIONS AND CORRECT ANSWERS

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What is a complication of pericarditis Cardiac tamponade What is Bex Triad? S/S of cardiac tamponade. Include: -Hypotension -Muffled heart sounds -JVD S/S of Pericarditis pericardial friction rub chest pain when lying down chest pain upon inspiration Who is more prone to infective endocarditis? ...

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NUR 308 EXAM 2 STUDY QUESTIONS
AND CORRECT ANSWERS
What is a complication of pericarditis ✅Cardiac tamponade

What is Bex Triad? ✅S/S of cardiac tamponade.
Include:
-Hypotension
-Muffled heart sounds
-JVD

S/S of Pericarditis ✅pericardial friction rub
chest pain when lying down
chest pain upon inspiration

Who is more prone to infective endocarditis? ✅IV drug users

What is a major complication of infective endocarditis? ✅Vegetative valve
Likely to become an embolism.

Vegetative growth can also lead to valvular stenosis + valvular insufficiency

Major manifestation of infective endocarditis ✅Osler's + Janeway Nodes (raised, red
areas on palms + soles of feet)

Why do we want to continue monitoring heart sounds in a patient with pericarditis and
endocarditis? ✅To determine if there are any new murmurs. This indicates a
worsening of the condition

What is an important patient teaching regarding infective endocarditis? ✅Source of
bacteria is the ORAL CAVITY.
High risk individuals should perform good oral hygiene.
Use soft toothbrush and NO IRRIGATION SYSTEMS!

What are some common forms of triggers to avoid in chronic condition? ✅Stress,
surgery, ILLNESS
(promote vaccinations)

First Stage (Mild Stage) of Alzheimer's ✅Can continue to perform ADl's.
Loss of smell (earliest finding)
Personality changes
NEW MEMORY LOSS!
Misplace household items

,*This person is in DENIAL*

Second Stage (MODERATE) of Alzheimer's ✅Impairment of cognitive functions
(difficulty paying bills, financial difficulty)

Often go missing at this stage/ get lost

Become confused in order of time, place, then person.

Agitation + mood swings

Nursing Diagnosis for Stage 2 of Alzhemier's ✅Risk for Injury (poor impulse control,
memory is poor, abused)

What should you do if an Alzheimer's patient is confused BUT calm? ✅Re-orient the
patient.

What should you do if an Alzheimer's patient is confused BUT agitated? ✅Utilize
validation therapy/ diversion techniques/ re-direction (activities)

Stage 3 of Alzheimer's ✅Patient is FULLY DEPENDENT for all ADL's.

Lose facial recognition

Traumatic relocation stress ✅Person with Alzheimer's moving from home environment
--> hospital.

Will become more confused and agitated.

In which stage is the Alzheimer's patient more prone to abuse? ✅Second stage.
Because of cognitive decline

Apraxia ✅inability to use words/ objects correctly.

ex. Not knowing what to do with house keys

Aphasia ✅Inability to speak and/or understand

Expressive- can't speak
Receptive- can't understand
Global- Both

Nursing Consideration: Request speech pathology referral

, Nursing interventions for somebody that has difficulty with expressive aphasia
(speaking) ✅Provide patient with pen + paper
Use of gestures
Be patient

How is Alzheimer's diagnosed? ✅Based on S/S and ruling out other possible causes

What is the number one concern for an Alzheimer's patient? ✅Risk for Injury

-Silver alert program
-Assist with ADL's in home
-Remove clutter
-Dead bolt locks to go outside
-Alarms

What is a key point regarding an Alzheimer's individual? ✅a PREDICTABLE
ROUTINE!

*Calm, Consistent, Predictable Environment*

Nursing Diagnosis for the Alzheimer's Patient ✅Risk for Injury
Chronic Confusion
Compromised Family Coping
Disturbed Sleep Pattern

What are the clinical manifestations of Parkinsons's dz? ✅Tremors at rest**
Rigidity (postural)
Akinesia/ bradykinesia
Postural instability

Nursing interventions that can be taught to reduce safety concern in a parkinsons
patient. ✅-teach pt. to use a wide stance (shoulder width)

-help them look upright and swing their arms

-if akinesia is present, gently rock themselves to get moving

-if experiencing rest tremors, use that hand/ extremity actively

Drugs used for Parkinsons patients ✅Levodopa
Anticholinergics
Antivirals
Dopamine receptor agonists
MOB Inhibitors
COM inhibitors

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