NUR 265 EXAM 4
Lupus: Hallmark sign Correct Answer: butterfly rash on face
Lupus: Indication of flare Correct Answer: Fever and fatigue
*also
... [Show More] assess BUN function
*c reactive protein remains normal
Lupus: Interventions Correct Answer: -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 Correct Answer: -hydroxychloroquine(anti-malarial) decreases absorption of UV light
Scleroderma Correct Answer: inflammatory, autoimmune connective tissue disease
Scleroderma: Hallmark Sign Correct Answer: Hard, leather-like edematous skin
Late: esophageal dismotility
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
small frequent meals--avoid caffeine and alcohol
-avoid spices, caffeine and pepper
fibromyalgia: S/sx Correct Answer: extreme fatigure
GI symptoms
dysuria
blurred vision
forgetfulness
fibromyalgia: Assess Correct Answer: pain level
extreme fatigue
GI symptoms
Fibromyalgia: Interventions Correct Answer: 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 Correct Answer: stage 1: "bulls eye rash" and flu-like symptoms
Stage 2: facial paralysis, carditis, meningitis
Lyme Disease: Assess Correct Answer: Skin
history of tick bites
Lyme Disease: Interventions Correct Answer: 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 Correct Answer: STOP THE INFUSION/ELIMINATE the trigger, then STOP the immune response
Give Epi
maintain airway
Latex allergy: risks Correct Answer: -frequent use of latex condoms
-healthcare workers
-allergy to avocados, bananas, and some nuts
Anaphylactic shock Correct Answer: 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 Correct Answer: 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 Correct Answer: -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 Correct Answer: CD4 count
ELISA test once per year for at risk patients
HIV: Interventions Correct Answer: 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 Correct Answer: high calorie
high protein
low fat
small frequent meals
thrush--treat with anitfungal
HIV tx: HAART/cART Correct Answer: DOES NOT CURE
Does not prevent secondary/opportunistic infections
MUST TAKE 90% of the time --otherwise resistance will occur
HIV: complications --- AIDS Correct Answer: CD4 count less than 200mmhg
most likely to experience opportunistic infections
--I.e Pneumocystic jiroveci pneumonia (ASSESS AIRWAY!!)
consult pallative care/hospice
candida albicans Correct Answer: -Hallmark sign-- white patches in the mouth
-"food doesnt taste right"
-If patient wants a coke they can have it! They just have to rinse mouth out with water (fungus loves sugar)
tuberculosis Correct Answer: hallmark sign-- night sweats, high fever, cough
-airborne isolation
-do not trust TB skin test in client with HIV
Fungal pneumonia Correct Answer: ABC's
monitor ABG--if hypoxemia present
antifungal drugs IV
External Radiation Correct Answer: -teach client to leave markings in place
-use sunscreen
-wash skin with mild soap and use lotion frequently [Show Less]