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Adult Health I > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

What type of disorders fall under the nervous system?

A

Seizures
Meningitis
Encephalitis
Parkinson’s
Multiple sclerosis
Migraine and cluster headaches
Cerebral vascular accident (CVA)/stroke

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2
Q

What is a seizure?

A

An abnormal electrical discharge in the brain. It interrupts normal brain function

Alters awareness, abnormal sensation, focal involuntary movements, or convulsions

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3
Q

What is epilepsy?

A

A chronic seizure disorder

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4
Q

What are the two different types of seizures?

A

Generalized
Partial

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5
Q

What is a generalized seizure?

A

Discharges occurs throughout the entire brain

Typically loss of consciousness

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6
Q

What is a partial seizure?

A

Only one half of the brain is affected.

Also called a focal seizure

Typically manifest as one structural abnormality

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7
Q

What are causes of seizures?

A

Genetics
Metabolic disorders
Mitochondrial diseases
Single gene mutation
Structural abnormalities (tumors, edema, increased ICP) ***brain stress

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8
Q

What are the phases of a seizure?

A

1) prodromal : mood or behavior starts to change (seizure may come in hours or days)

2) aura: premonition of impending seizure (visual, auditory, or gustatory)

3) ictal : seizure activity (usually musculoskeletal)

4) postictal : period of confusion / somnolence/ irritability that happens after the seizure

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9
Q

Manifestations of seizures

A

-aura
-short duration (1-2 minutes)
-postictal state
-Todd paralysis : in some people, one side of the body is weak and weakness last longer than the seizure
-Visual hallucinations
-Convulsions

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10
Q

How do you diagnose a seizure?

A

-head CT
-MRI
-EEG
-Lumbar puncture
-Electrolyte study
-Prolactin levels

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11
Q

What medications are used to manage seizure disorders?

A

Made medication is an anticonvulsant

Examples:
Levetiracetam (Keppra)
Carbamazepine
Oxcarbazepine
Lamotrigine
Phenytoin
Valproic
Fosphenytoin
Gabalentin

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12
Q

What are non-medication options to help manage seizure disorders

A

-Special diet (ketogenic/Atkins)
-Vagal nerve stimulation
-Implantable neurostimulator
-Lobectomy/lesionectomy
-activity modification/restrictions (driving, climbing, ladders, cooking, power tools/dangerous equipment, swimming, baths)

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13
Q

Nursing diagnoses (risks associated with) seizures

A

-Risk for trauma or suffocation
-Risk for an effective airway clearance
-Situational, low self-esteem
-Deficient knowledge
-Risk for injury

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14
Q

What history needs to be gathered during a nursing assessment for seizures

A

-Age they were at onset
-Frequency
-treatments they’ve had
-What are symptoms/manifestations are

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15
Q

What are nursing interventions for a seizure disorders?

A

-prevent injury
-Maintain airway
-educate patient and family (safety, triggers, compliance with meds)

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16
Q

What is meningitis?

A

Inflammation (swelling) of the protective membranes, covering the brain and spinal cord. Can lead to ICP

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17
Q

What are the causes of meningitis?

A

Usually caused by an infection:
Bacterial
Viral
Fungal
Parasitic
Amebic

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18
Q

What are the manifestations of meningitis?

A

Fever
Seizure
Neck stiffness
Positive Kernig’s sign
Positive brudzinski sign
Neurologic symptoms
Photalgia (photophobia)

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19
Q

What is Positive brudzinski sign?

A

Lift head up to put chin to chest, with involuntary flexing of hips and knees *a reaction to the stretch)

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20
Q

What is a positive Kernig’s sign?

A

(inability to extend knees more than 135 degrees)

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21
Q

What is the worst kind of meningitis?

A

Bacterial meningitis
Specifically; meningococcal

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22
Q

Where is Meningococcal meningitis commonly seen

A

Communal living situation
College dorm
Military barracks 

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23
Q

What are signs and symptoms of bacterial meningitis?

A

Fairly sudden onset of the following symptoms
Fever
Headache
Stiff neck
Rush

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24
Q

What are other possible signs of bacterial meningitis?

A

Nausea/vomiting
Sensitivity to light
Confusion
Drowsiness
Convulsions
Joint pain
Cold hands and feet
,coma

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25
Q

How does bacterial meningitis manifest in children/infants?

A

Lethargy*****
Poor eating
Difficult to wake
Sleepiness
Crying when handled
Irritability
Grunting or difficulty breathing
Bulging of the frontenelle
High-pitched crying
Convulsions
Vomiting
Pale or blotchy skin
Abnormal reflexes
Coma

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26
Q

What is different about viral meningitis?

A

-Can be caused by any virus
-Not as severe as bacterial, and can often self resolve
-It can cause lasting neurological deficits

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27
Q

How do you diagnose meningitis?

A

Lumbar puncture
CBC
Blood culture
Head CT

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28
Q

How do you treat bacterial meningitis?

A

-Antibiotics
-Control fever and pain
-IVF (IV fluids)
-Possible mechanical ventilation
-Possible ICP monitoring

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29
Q

How do you treat viral meningitis?

A

-Antiviral medication
-Control pain and fever
-IVF
-Possible mechanical ventilation

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30
Q

What are the main things that need to be assessed for meningitis?

A

-Neurological status
-Pulse ox
-Arterial blood gas

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31
Q

What are nursing diagnoses (risk of developing) for meningitis

A

-Infection
-Acute pain
-Impaired physical mobility
-Activity intolerance
-impaired skin integrity
-injury
-Interrupted family process
-Anxiety

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32
Q

What are nursing considerations for treating a patient with meningitis?

A

-HOB elevated (semi Fowlers position)
-Neurochecks
-Pain assessment
-Limit stimulation (dark, quiet room)
-Manage nausea (vomiting, and increased ICP)

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33
Q

What is encephalitis?

A

Inflammation of cerebral tissue

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34
Q

What causes encephalitis?

A

Most commonly caused by the herpes virus

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35
Q

What are manifestations of encephalitis?

A

Fever
Headache
Nausea/vomiting
Mental status changes
Meningeal signs (stiff neck, photophobia)
Seizures
Motor deficit
Personality changes
Sign of brainstem involvement

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36
Q

What are signs of brain stem involvement?

A

Nystagmus (eye twitching)
extraocular nerve palsies
Hearing loss
Dysphagia
Respiratory dysfunction

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37
Q

What medications are used to treat encephalitis

A

Antivirals
Anticonvulsants
Steroids
Pain management
Sedatives

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38
Q

What is Parkinson’s disease?

A

A degenerative disease that is caused by depletion of dopamine

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39
Q

What does depletion of dopamine lied to my garden Parkinson’s?

A

-Dysfunction of the extrapyramidal system
-slow, progressive disease, that results in a crippling disability
-Can result in Falls, self-care, deficits, failure of body systems, depression

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40
Q

When does mental deterioration occur in Parkinson’s disease?

A

In the late stages

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41
Q

What are causes of Parkinson’s disease?

A

Hereditary
Drug induced (dopamine, depleting drugs)

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42
Q

What are examples of dopamine depleting drugs?

A

Reserpine
Phenothiazine
Metocloprmide
Tetrabenazine
Droperidol
Haloperidol

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43
Q

What are manifestations of Parkinson’s?

A

-Bradykinesia
-Akinesia
-monotonous speech
-handwriting become smaller
-Tremors
-Pill rolling
-Rigidity with jerky interrupted movements
-restlessness and pacing
-Mask (blank, facial expression)
-Drooling
-Difficulty swallowing and speaking
-loss of coordination and balance
-Shuffling steps, stooped position, propulsive gait

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44
Q

What are nursing diagnoses (risks of) Parkinson’s disease

A

-ineffective airway clearance
-Disrupted thought process
-impaired verbal communication
-Impaired physical mobility
-Imbalanced nutrition
-Impaired swallowing
-Risk for injury
-Self-care deficit

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45
Q

How do you diagnose Parkinson’s?

A

Physical exam
Levodopa challenge (put them on med and see if there’s an improvement)
PET
MRI

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46
Q

What are the medical/medication used to manage Parkinson’s disease?

A

Levodopa
Neurosurgery
Neurologic implants
PT/OT

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47
Q

How can nurses help manage Parkinson’s disease?

A

-Assassin neurological status
-Accessibility to chew and swallow
-Diet
-Increase fluid intake do 2000 ML per day
-Monitor for constipation
-Promote independence with safety measures
-Do not rush patient
-Assist with ambulation
-Ambulation devices
-Instruct patient to rock back-and-forth to initiate movement
-Instruct the client to wear low heeled shoes
-lift feet when walking
-Firm mattress ***
-promote proper posture with hands help behind back
-Promote physical therapy and rehabilitation
-Administer in monitor meds
-Avoid foods high in B6
-Avoid monoamine oxidase inhibitors

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48
Q

What is the proper diet for someone with Parkinson’s disease?

A

High calorie
High protein
High-fiber
Soft
Small
Frequent feedings

NO B6

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49
Q

Why give a firm mattress to a patient with Parkinson’s?

A

Firm mattress with pt positioned in prone position without pillow to facilitate proper posture

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50
Q

What is multiple sclerosis?

A

Chronic, progressive, non-contagious, degenerative disease of the CNS

Demyelinization of neurons

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51
Q

What is attacked during multiple sclerosis?

A

Myelin sheath around the nerves

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52
Q

What are the causes of multiple sclerosis?

A

Unknown
Might be autoimmune

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53
Q

What are risk factors that can lead to multiple sclerosis

A

Pregnancy
Fatigue
Stress
Infection
Trauma

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54
Q

Manifestations of MS

A

-fatigue and weakness
-ataxia (impaired balance or coordination)
-vertigo
-tremors
-Blurred vision and diplopia (double vision)
-nystagmus (dancing eyes)
-Dysphasia
-decreased perception to pain, touch, temp
-bladder and bowel disturbances (urgency, frequency, retention, and incontinence)
-emotional changes (apathy, euphoria, irritability, depression)
-Memory changes and confusion

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55
Q

How to diagnose MS

A

Lumbar puncture (CSF is high in IgG *imnuno globulin) and Myelin)
EEG
CT
MRI

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56
Q

What is medical management for MS

A

Corticosteroids
Immunomodulatory agents
Muscle relaxants
Other meds to address individual symptoms

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57
Q

What are nursing diagnosis (risk for) MS

A

-fatigue
-self-care deficit
-Low self-esteem
-powerlessness/hopelessness
-Risk for ineffective coping
-ineffective, family coping
-Impaired urinary elimination

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58
Q

What are nursing interventions for MS

A

-provide bedrest during exasperation
-Protect from injury
-Place eyepatch for diplopia
-Monitor for potential complications
-promote regular elimination
-Encourage independence
-Assist client to establish regular exercise and rest
-Instruct the client to balance, moderate activity with rest
-provide assistive devices
-Initiate physical and speech therapy
-Increase fluid in taking a balanced diet
-Safety measures
-Follow meditation routine

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59
Q

What is a migraine headache?

A

Neurovascular disorder that causes severe head pain

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60
Q

How long do migraines typically last?

A

4 to 72 hours

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61
Q

What is an aura in regards to migraine

A

A visual or sensory disturbance
Types of auras include
Flashing lights
Spots and vision
Dizziness/vertigo
Nausea
Aphasia

62
Q

What are causes of migraine headaches

A

Possible activation of the CN V
Dilation of cerebral arteries
Similar features to seizures

63
Q

What are risk factors for migraine, headaches

A

Family
Gender : women are more prone

64
Q

What are potential triggers for migraine headaches

A

Bright/flashing lights
Stress
Anxiety
Menstruation
Sleep deprivation
Food : especially food, containing MSG, or Tyramine

65
Q

What foods are high in Tyramines

A

Red wine
Hard cheese
Aged meat products

66
Q

What are manifestations of migraines?

A

Throbbing head pain
Nausea/vomiting
Photophobia
phonophobia

67
Q

How do you diagnose migraine headaches

A

Labs
CT (to rule out other cerebral pathology)
Sleep study (correlation between migraines and sleep apnea)

68
Q

What are medical management options for migraines?

A

NSAIDs
Eegotamine
Triptan meds
Calcitonin gene relates peptide receptor antagonist
Caffeine
Nausea meds
Seizure meds
Beta blockers

69
Q

What does patient education regarding migraine, headaches

A

Identify and avoid triggers
Provide dark and quiet environment
Administer meds as directed

70
Q

What a cluster headaches

A

A specific migraine variant (throbbing)
Unilateral
Typically occurs at the same time of day
More common in the spring, and fall

71
Q

What are causes for cluster

A

Similar to migraine
Potential sudden release of histamine or serotonin at the CNV

72
Q

What are manifestations of cluster headaches

A

Severe, unilateral have pain
Often behind that eye
Accompanied by : nasal congestion, facial, sweating, drooping eyelids, tearing, generalized agitation

73
Q

Risks, diagnostics, and medical management for cluster headaches

A

Same as migraine

74
Q

What is a CVA (stroke)

A

Cerebral vascular accident

A disruption of the blood supply to part of the brain

Sometimes called TIA (transient, ischemic attack)

75
Q

What can CVA/stroke cause

A

Temporary or permanent loss of movement, thought, memory, speech, or sensation

76
Q

What are risk factors for CVA?

A

-Age (55+)
-Gender (male)
-Race (African-American)
-Hypertension
-A fib
-Hyper lymphedema
-Obesity
-smoking
-Diabetes
-Periodontal disease
-asymptomatic, carotid, stenosis, and that’s valvular heart disease

77
Q

What are the two causes of strokes?

A

1) ischemic
2) Hemorrhagic

78
Q

What is an ischemic cause for CVA?

A

block
Thrombotic
Emboli
60% occur during sleep

79
Q

What is a hemorrhagic it cause for a CVA

A

bleeding
-Elevated BP
-Bleeding disorder
-AV malformation (aneurysm)

80
Q

What is the acronym for recognizing a stroke?

A

Be fast

Balance
Eyes
Face
Arms
Speech
Time

81
Q

What are the manifestations of CVA?

A

-Numbness or weakness of the
Face
-Changes in mental status
-Trouble speaking
-Trouble understanding speech
-Visual disturbances
-Homonymous hemianopsia (visual loss of one side)
-loss of peripheral vision
-Hemiparesis (weakness on one side of body)
-HemiPlegia
-ataxia
-Dysarthria (difficulty changing the volume of speech)
-Dysphasia
-Paresthesia
-expressive aphasia
-Receptive aphasia
-Global aphasia

82
Q

What is expressive aphasia?

A

Aka Broca’s aphasia

Person knows what they want to sing, happier and able to produce the words or sentence

They cannot properly express themselves

83
Q

What is receptive aphasia

A

Aka wernickes aphasia

Difficulty, understanding, written, and spoken language

84
Q

What is global aphasia?

A

Affects both expressive and receptive

85
Q

How do you diagnose ETA?

A

12 lead EKG
CT
Doppler studies
Arteriography

86
Q

How do you assess CVA?

A

Understand time of onset is crucial
Past medical history
Vital signs
Neuro check
Aphasia

87
Q

What is the treatment for CVA?

A

ABC’s
Control blood pressure
Anticoagulant (after hemorrhage has been ruled out)
Neuroprotective agents
TPA

88
Q

How should nurse is assessing CVA?

A

-change in LOC or responsiveness
-Presence or absence of voluntary or involuntary movements of extremities
-Stiffness or facility of the neck
-eye-opening, comparative size of people and pupillary reaction to light
-Color of the face and extremities
-temperature and moisture of the skin
-Ability to speak
-Presence of bleeding
-maintenance of blood pressure
-Mental status
-Motor control

89
Q

What are nursing diagnosis (risks involved with) CVA?

A

-impaired physical mobility
-Acute pain
-Disturb sensory perception
-Deficient self-care
-Impaired urinary elimination
-Disturbed that process
-impaired verbal communication
-Risk for impairs can integrity
-Interrupted family process
-Sexual dysfunction

90
Q

What are nursing interventions for CVA?

A

Positioning
Prevent Flexion
Prevent adduction
Prevent edema
Full range of motion
Prevent venous stasis
Regain balance
Personal hygiene
Manage sensory difficulties
Visit a speech therapist
Avoiding pattern
Be consistent with patient activities
Assess skin

91
Q

What are discharging home care/education for patients who have had a CVA

A

Consult an occupational therapist
Physical therapist
Antidepressant
Support group
Assess caregivers

92
Q

What is Bell’s palsy?

A

Affects cranial nerve number 7
-Caused by irritation of a nerve (usually viral)
-causes unilateral facial paralysis
Looks like CVA, but other muscles are not affected

93
Q

What does management for Bell’s palsy?

A

Oral steroids
Antiviral medication
NSAIDs
May require taping close the effected eyelid

Usually results within 7 to 10 days

94
Q

What does diabetes mellitus mean?

A

Diabetes: excessive urination
Mellitus : sweet tasting

95
Q

what does glucagon do?

A

Signals delivered to release glucose

96
Q

What does insulin do?

A

Take glucose into the cells

97
Q

What works together to help maintain appropriate blood glucose level

A

Insulin and glucagon

98
Q

What is normal blood glucose level?

A

Between 70-100 mg/dl

99
Q

What are pre-diabetic levels

A

100-125

100
Q

What are DM levels

A

> 125

101
Q

What is type one diabetes?

A

Autoimmune disorder
Body does not make insulin (bc Islet cells are destroyed)

Extra info:
-kidneys can only reabsorb so much glucose
-Extra is Peed out
-Fluid follows the glucose leading to dehydration
-body starts to break down fat leads to key tones
-Fruity breath

102
Q

What is type two diabetes?

A

Cells become resistant insulin
“ rusty lock”

Sometimes there is a decrease in insulin production

103
Q

What are the causes for type two diabetes?

A

Family history/genetics
Obesity
Prolong steroid use

104
Q

What is gestational diabetes

A

Placental, hormones, cause insulin resistance

Mothers levels go back to normal after birth

105
Q

What are the names of rapid acting insulin

A

Lispro
Aspart
Glulisine

106
Q

What is the name of short acting insulin

A

Regular

107
Q

What is the of intermediate insulin

A

NPH

108
Q

What are the names of long acting insulin?

A

Glargine
Determir

109
Q

Rapid acting insulin
Onset
Peak
Duration

A

15-20 mins
1-2 hours
4-6 hours

110
Q

Short acting insulin
Onset
Peak
Duration

A

30mins - 1 hr
2-4 hrs
6-8 hrs

111
Q

Intermediate acting insulin
Onset
Peak
Duration

A

2-4 hrs
8-10 hrs
14-20 hrs

112
Q

Long acting insulin
Onset
Peak
Duration

A

1-2 hrs
None
24 hrs

113
Q

What are the 5 oral meds for diabetes

A

-biguanides
-sulfonylureas
-alpha-glucosidase inhibitors
-Thiazolidinediones
-dipeptidyl-peptidase -4

114
Q

What is the main biguanides

A

Metformin

115
Q

What are the main sulfonylureas?

A

-Glipizide
-Glimepiride

116
Q

What is the main thiazolidinediones

A

Pioglitasone

117
Q

What is the main dipeptidyl-peptides-4

A

Sitagliptin

118
Q

What are patients at risk for who have diabetes (nursing diagnosis)

A

-unstable blood glucose levels
-Infection
-deficient knowledge
-disturbed sensory perception (lack of nerve endings)
-impaired skin integrity
-Ineffective peripheral tissue perfusion

119
Q

What are nursing priorities when handling diabetes

A

-restore fluid/electrolytes
-correct/reverse metabolic issues
-identify/assist with underlying causes
-prevent complications
-educate

120
Q

What are characteristics / manifestations of asthma

A

Cough
Dyspnea
Wheezing

121
Q

What are the main medications for respiratory disorders

A

1) short-acting beta 2 (in the lungs) -adrenergic agonists (SABA)
2) anticholinergics
3) corticosteroids
4) leukotriene modifiers
5) immunomodulators

122
Q

What do shirt-acting beta 2 adrenergic agonists (SABA) do?

A

Nebulizer
-albuterol
-ipratropium
-

Treat acute symptoms and prevention of exercise induced asthma.

123
Q

How do anticholinergics work?

A

Inhibit muscarinic cholingergic receptors

Reduce intrinsic vagal tone of airway

124
Q

How do corticosteroids work?

A

Alleviating symptoms, improving airway function, decreasing peak flow variability

125
Q

How do leukotriene modifiers work?

A

Anti- leukotrienes are bronchoconstrictors, so leukotrienes dilate blood vessels and alter permeability

126
Q

How do immunomodulators work?

A

Prevent binding IgE to the high affinity receptors of basophils and mast cells

127
Q

How do you measure pulmonary function ?

A

-tidal volume (TV)
-minute volume (MV)
-vital capacity (VC)
-functional residual capacity (FRC)
-residual volume

128
Q

What is tidal volume?

A

“Normal breathing”

Amount of air inhaled or exhaled during normal breathing

129
Q

What is minute volume?

A

Total amount of air exhaled per minute

130
Q

What is vital capacity?

A

Total volume of air that can be exhaled AFTER inhaling as much as you can

131
Q

What is functional residual capacity?

A

amount of air left after exhaling

132
Q

What is residual volume?

A

Amount of air left in lungs after exhaling as much as possible

133
Q

What is total lung capacity?

A

Total volume of the lungs when filled with as much air as possible

134
Q

What is forced vital capacity?

A

Amount of air exhaled forcefully and quickly after inhaling as much as you can

135
Q

What is forced expiratory volume

A

Amount of air expired during first, second, and third seconds of FVC test

136
Q

What is forced expiratory flow?

A

Average rate of flow during the middle half of FVC test

137
Q

What is peak expiratory flow rate?

A

Fastest rate that you can force air out of your lungs

138
Q

Describe chronic bronchitis
“Blue bloater”

A

Overweight
Cyanotic
Elevated hemoglobin
Peripheral edema (extra weight)
Rhonchi and wheezing

Daily productive cough for 3 months or more, in 2 consecutive years

139
Q

Describe emphysema
“Pink puffers”

A

-older and thin
-severe Dyspnea
-quiet chest
-X-ray hyperinflation with flattened diaphragms

140
Q

What are adverse reactions to inhaled anticholinergic

*ipratropium

A

Dry mouth
Irritation of pharynx
Increased intraocular pressure
Urinary retention

141
Q

What are the adverse reactions to Methylxanthines

*theophylline

A

When exceeded:
Restlessness
Insomnia
Nausea
Vomiting
Diarrhea

Toxic levels
Seizures
Dysrhythmias

142
Q

What are adverse reactions to glucocorticoids

*beclomethasone

Inhaled, long term
Prednisone, short term

A

Inhaled:
Oral candidiasis

Oral:
Suppression of adrenal function
Bone demineralization
Muscle wasting
Hyperglycemia
Peptic ulcer disease
Infection
Fluid and electrolyte imbalances

Nasal:
Dry mucous membranes
Epistaxis
Sore throat
Headache

143
Q

What are the adverse reactions for mast cell stabilizers

*Cromolyn

A

Allergic reaction with known allergies

144
Q

What are adverse reactions to Leukotriene modifiers

*Montelukast

A

Zileuton/Zafirlukast = cause liver damage

Montelukast = neuropsychiatric effects (SI)

145
Q

Drug therapy for upper respiratory disorders

A

-1st gen antihistamine/sedating
-2nd gen antihistamine/nonsedating
-sympathomimetics
-antitussives
-expectorants
-mucolytics

146
Q

What is a 1st generation antihistamine/ sedating

Adverse reactions

A

*diphenhydramine
(Benadryl)

Drowsiness
Dizziness
Anticholinergic (dry mouth, constipation)

147
Q

What is a 2nd generation antihistamine/ nonsedating

Adverse reactions

A

*cetrizine

Management of allergic rhinitis, chronic idiopathic urticaria

Drowsiness
Fatigue
Anticholinergic (dry mouth, nose, and throat)

148
Q

What is an example of sympathomimetics

Adverse reactions

A

*Phenylephrine

Allergic rhinitis, sinusitis, and the common cold

-CNS stimulation with oral agents (agitation, anxiety, insomnia)

-increased blood pressure

-tachycardia/ palpitation

-OD/ systemic absorption (hypertension, tachy, and heart rate palpitations)

-rebound congestion w/ prolonged use of topical agents

149
Q

What are examples of antitussives

Adverse reactions

A

*codeine (opioid)
*dextromethorphan (non-opioid)

Suppression of chronic / nonproductive cough

-CNS depression (drowsiness, sedation)
-dizziness
-lightheadedness
-gastrointestinal distress (nausea/vomiting)
-constipation
-respiratory depression
-potential abuse

150
Q

What are examples of expectorants

Adverse reactions

A

*guaifenesin

Coughs- break up mucus so it can be coughed up

Dizziness
Deowsines
Headache
GI distress
Allergic reaction

151
Q

What are examples of mucolytics

Adverse reactions

A

*acetylcysteine

Decreases viscosity of mucous secretions
Reverse Tylenol OD

Brochospasms
GI distress (rotten-egg smell)

consume 2000 to 3000 ml of water

Adult Health I (10 decks)

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