Exam 2 Prep Flashcards
What lab finding and assessment would you find a patient who had a UTI and were administering you UA (what would the urine look like)
- The urine would be cloudy
2. Positive nitrites
What are the proper procedures in urine culture in antibiotic administration?
Collect the culture before administering the IV antibiotic
What is the cause of catheter associated UTI (CAUTI)?
Indwelling urinary catheter
What is a S/S of pyelonephritis?
Left sided flank pain
What is the discharge teaching for a female patient that was treated for a UTI?
Wipe from font to back
What is a clinical manifestation that is related to pneumothorax?
- Chest pain or chest discomfort
2. Tachypnea
What is a S/S of tension pneumothorax?
Medial sinal shift
What is the initial treatment of tension pneumothorax?
Needle decompression
What is the cause of iatrogenic (injury or illness caused by medical treatment or exam) pneumothoresis?
Insertion of a central line
What is otorrhea?
Drainage from the ears
What is rhinorrhea?
Drainage from the nose
We have a patient presenting S/S of pneumothorax. How would you assess them? What would you look for?
- Auscultating their breath sounds
- Assess the expansion of their chest
- Looking for any deviation in position of their trachea (trachea alignment)
What are the S/S of simple pneumothorax?
Diminished breath sounds
What is the pathophysiology of an epidural hematoma?
Blood accumulates between the skill and the dura mater (the thick membrane covering the brain)
What is the cardinal symptoms that this patient with epidural hematoma have?
Brief loss of consciousness
What is the S/S of a basilar skull fracture?
Racoon eyes
What is the pathophysiology of a subdural hematoma?
Bleeding in the space below the dura mater and above the subarachnoid membrane
If a patient comes into the ER with drainage from the ears and drainage from the nose, what is the most concerning?
When you can see clear drainage or CSF halo around the blood
What is the priority assessment of a pt coming with a TBI?
Their level of consiousness. You need to establish a baseline using the GCS (Glasgow coma scale), and monitor them for deterioration
List the early S/S of ICP
- Restlessness
- Decreased LOC
- Increased CO2`
What is the diagnostic prioritization of a pt with S/S of a stroke?
CT Scan
What is a tPA and what kind of patients is it used for?
A thromolytic - its a powerful clot buster that DISSOLVES the clot and is used for pts with ischemic stroke with in a 4.5 hour window
List the modifiable risk factors for stroke?
- Smoking
- Obesity
- Sedentary lifestyle
Describe decorticate posture:
Arms are up toward the core and flexed / feet are pointed in
Describe decerebrate posture:
Everything is extended
In the Monroe Kelly Hypothesis, list the 3 main components of the cranium:
- Blood
- CSF
- Brain Tissue
What is the normal pH value for ABG?
7.35 - 7.45
What is the normal PaCO2 value?
35 - 45 mmHg
What is the normal HCO3 value?
22 - 26 mEq / L
The nurse is evaluating the tuberculin skin test (TST) for a patient who has a diagnosis of human immunodeficiency virus (HIV). The skin test is positive if the area of induration is at least __ mm?
5
A diagnosis of pneumonia is typically achieved by which of the following diagnostic test?
Chest x-ray
The physician orders a urine culture on your patient with a urinary tract infection. In addition, the patient is ordered to start IV antibiotics. How will you proceed with following this order?
First, collect the urine culture, and then hang the antibiotic.
You’re providing discharge teaching to a female patient on how to prevent urinary tract infections. Which statement is INCORRECT?
“Use scented sanitary napkins or tampons during menstruation.”
A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?
Laceration of the middle meningeal artery
An awake, alert patient arrives at the ED following a fall down a flight of stairs. The physician suspects a basilar skull fracture. Which assessment findings should the nurse anticipate?
Rhinorrhea and raccoon eyes
An 11 year-old boy with skin lesions on his trunk characteristic of ringworm has been brought to the health care provider. Which aspect of the clinician’s assessment relates most directly to the suspected diagnosis?
Potential contact with the fungus from pets or other children
A 13 year-old girl has presented to a clinic with her mother explaining that she had an oval-shaped red patch on her chest a week ago, but that more of the lesions are now appearing on her back. On examination, the lesions on her back are in a “Christmas tree” pattern. What is the girl’s most likely diagnosis?
Pityriasis rosea
The following are types of pneumothoraces except:
Direct
Clinical manifestations related to pneumothorax include all of the following except:
Acrocyanosis
Significant early signs of a ruptured cerebral aneurism:
Severe head ache
Neucorigidity (stiff neck)
Photophobia (sensitive to light)
The following are the main components in the cranium:
CSF
Blood
Brain tissue
A nurse assesses a patients GCS:
Open the eyes spontaneously, obeys verbal commands
and is oriented
Which of the following would be priority for this patient with decreasing LOC?
Risk for aspiration and ability to protect the airway
In the acronym FAST, what does T mean?
Time: the patients last known well time
For discharge teaching with a patient that had a stroke what are the modifiable risk factors?
Obesity
Sedentary lifestyle
Smoking
CO2 level of 52 (high)
Hypercapnia
The pt has an elevated ICP:
Causes vasodilation and increases ICP
A pt with left sided weakness, or CVA, what diagnostic test is used to confirm this?
CT scan
A pt has a GCS of 14 then drops to 10 what does this mean for the pt?
They exhibit a deteriorating neurological status
All the following are S/S of stroke EXCEPT:
Bilateral Joint pain
What is the following outcome of a thrombolytic drug therapy for stroke?
Dissolves the emboli
What is the term used for slurred speech or having a hard time speaking?
Dysarthria
