Exam 2 Blue Print Flashcards
What lab finding and assessment would you find in a patient who has a UTI and were administering a UA (What would the urine look like)?
- Urine would be cloudy
- Positive nitrites (nitrATEs convert into nitrITES)
(signs to confirm bacteria)
What is the proper procedure if a Dr. orders a urine culture on a patient who had a positive UA and they are wanting to determine what microorganism is causing it? and how to treat it?
Collect the culture before administering the IV antibiotic
What are causes of catheter associated UTI (CAUTI)?
Indwelling urinary catheter (Foli catheter) {the longer the patient has it the more likely they are to contract a UTI}
What is a sign and symptom of pyelonephritis?
Left sided flank pain
What is the discharge teaching for a female patient with a UTI?
Wipe from front to back (to prevent contact from urethra and fecal matter)
What is the clinical manifestations related to pneumothorax?
- Chest pain or discomfort
2. Tachypnea (fast RR)
What are the signs and symptoms of tension pneumothorax?
Medial sinal shift
What is the initial treatment of tension pneumothorax?
Needle decompression
In iatrogenic pneumothoresis (injury or illness caused by medical treatment or exam) what causes this?
Insertion of a central line
What is otorrhea?
Drainage from the ears
What is rhinorrhea?
Drainage from the nose
If a patient comes into the ER with drainage from the ears and drainage from the nose, what is the most concerning?
CSF halo around the blood
What is the priority assessment of a patient coming in with a TBI?
Level of consciousness to establish baseline and monitoring them for deterioration (use the GCS)
List the early signs and symptoms of ICP:
- Restlessness
- Decreased LOC
- Increased CO2
What is the diagnostic prioritization of a patient with S/S of a stroke?
CT scan
What is a tPA?
A thrombolytic - clot buster - dissolves a clot
What is a tPA used for?
A patient with ischemic stroke with in a 4.5 hour window
What are the modifiable risk factors for a stroke?
- Smoking
- Obesity
- Sedentary lifestyle
Describe decorticate posturing?
Arms are flexed up to the core
Describe decerebrate posturing?
Everything and the arms are extended
In the Monroe Kelly Hypothesis, what are the 3 main components in the cranium?
- Blood
- CSF
- Brain tissue
We have patient presenting S/S of pneumothorax. How you would assess them and what would you look look for?
- Auscultating their breath sounds
- Assess the expansion of chest (looking for equal movement)
- Any deviation in position of the trachea
- Tracheal alignment
What is the S/S of simple pneumothorax?
Diminished breath sounds
What is the pathophysiology of an epidural hematoma?
Blood accumulating between the skull and the dura mater
What is the cardinal symptom that this patient will have (epidural hematoma)?
Brief LOC
S/S of a basilar skull fracture?
Racoon eyes
What is the pathophysiology of a subdural hematoma?
Bleeding in the space below dura mater and above the subdural arachnoid
What are the 3 different types of pneumothorax?
- Tension
- Simple
- Open (sucking chest wound)
What type of isolation is required for TB patients?
Airborne precautions
What is the organism that causes walking pneumonia?
Mycoplasma pneumonia
PPD tests/ TB skin test, what would a negative skin test look like v.s. a positive skin test?
POS = induration, redness, 5 mm lesion NEG = no bumps or redness
A patient with pneumonia: How would we prioritize our assessment, after the airway, what would be the priority assessment in intervention with a pt with pneumonia?
Breathing - pulse ox - if its low we give them O2 oxygen would be a priority for hypoxic pneumonia pt or pneumonia with difficulty breathing
When a pneumonia pt comes into the hospital and labs are drawn, what would you expect to see with their CBC in particular?
Increased WBC (the source of their infection is bacterial)
What is the cause of ringworm?
A highly contagious and transmittable fungus {contact with a fungus and that is how ringworm is caused}
Pathophysiology of pressure ulcers:
Pressure on boney prominences when this happens the blood flow to that area is decreased {if pt has a condition where they cannot shift their weight, this is a problem i.e. the elderly because sensation decreases as we age and they are at an increased risk because of the pressure on those areas}
Pathophysiology of burns:
Increased capillary permeability when there is a significant burns occurring across the body surface area {causes hypovolemia - which causes edema}
What is the Parkland Formula Fluid Calculation:
4 mL x % of body tissue that is burned x patients weight in Kg = __________ / divided by 2
Pathophysiology of basal cell carcinoma: neoplasm cancer or tumor of the non-keratinized
Non- Keratinizing cells of the basal layer of the epidermis (ex: moist areas of the body like the tongue)
If the CO2 is on the same side as the pH it means:
Respiratory
If the HCO3 is on the same side as the pH is means:
Metabolic
If it is mixed or normal it means:
No compensation
What is the normal values for pH:
{below = acid} 7.35 - 7.45 {above = alk}
What is the normal values for paCO2:
{below alk} 35 - 45 {above acid}
What is the normal values for HCO3:
{below = acid} 22 - 26 { above = alk}
What are the types of body fluids HIV can be transmitted though?
- Blood
- Breast milk
- Bodily secretions and semen/ vaginal fluid
How does HIV respond to antiretroviral medications?
Increases the CD4 cell count / decrease viral load
Pathophysiology of CD4 cells infected by the HIV virus:
HIV kills the CD4 - CD4 cell death
Infection prevention: In AIDS pt, what would we tell these patients to do to prevent their own infection (to prevent opportunistic infections)
- Practice good handwashing
- Practice good aseptic technique when performing sterile procedures
- Be mindful that they are immunocompromised when CD4 levels are low
Pt teaching: Nurse teaching pt how to prevent the actual spread of HIV/AIDS to the population:
- Condoms
- Razors - no
- Sharing tooth brushes
S/S of Meningitis:
- Stiff neck
- Photophobia
- Sudden and severe headache and a fever
- POS Brazinski sign
Define ketogenic diet:
High fat - low cholesterol
Why would a patient be on a ketogenic diet pertaining to a seizure disorder?
This diet produces ketones - which leads to better seizure control
List the priority interventions for a pt during a seizure:
- Protect the airway {airway precautions}
Type of isolation precautions for pt with meningitis:
Droplet precautions
What is the priority assessment for the patient with meningitis?
LOC is priority {need to est baseline LOC like using GCS}
What is the most common cause or mechanism of spinal cord injury?
MVC - motor vehicle crash
What are some clinical manifestations of spinal cord injury?
- Loss of sensation or flaccid paralysis
- Loss of deep tendon reflexes
- Incontinency
What would be assessment priority with pt with spinal cord injury?
Airway
Pathophysiology of spinal shock:
- Flaccid paralysis
Causes of autonomic dysreflexia:
Nauctious stimuli- actual or potential tissue damaging event, ,like MVC, to the spinal cord
