Exam 2 Study Guide: Q Flashcards
what is the 3 step approach to managing pain?
- nonopioid drug (ibuprofen, tylenol)
- mild opioid (norco, ultram) in combination with the same or a new nonopioid
- stronger opioid (morphine, oxycodone)
what information should the nurse obtain when a client reports pain?
assess all aspects of the pain -
character, onset, location, duration, exacerbation, relief, and radiation. PQRST
what type of pain manifests with nausea, vomiting, and restlessness?
acute pain:
sudden in onset and usually of short duration, presenting immediately after noxious stimuli and tissue damage and continuing for several hours to several weeks
who is at an increased risk for opioid induced constipation and what can you do to reduce the risk?
older adults
increasing daily water intake and fiber-rich foods
what are the goals of CAM?
promotion of wellness
prevention of illness
reduction in treatment side effects
improvement of the immune system
enhancement of quality of life
what should you determine about clients who are interested in CAM?
a thorough assessment of the client’s attitudes related to CAM to determine their readiness to learn
s/s of lupus?
FATIGUE
oral ulcers
thinning hair
butterfly (malar) rash
joint tenderness
pleural or pericardial effusions
renal disease
neurological disorders
hematological disorders
how is lupus confirmed?
confirmed through positive antinuclear antibody test - ANA
when a patient with RA has red, hot, swollen joints, this indicates what?
a medical emergency:
- could be an infection
what exercises should be encouraged for RA patients?
range of motion:
- to promote joint mobility, reduce stiffness, and improve muscle strength.
aerobic exercise:
- to promote cardiac health.
rest periods:
- to manage fatigue and joint pain
what are risk factors for OA?
excessive use
age
obesity
(being female not risk factor)
encourage use and walking to help with OA
a BMI > 30 is a risk factor for which disease?
gout
s/s of gout
severe pain
redness
swelling in great toe
how can gout patients reduce the formation of urinary stones?
increased fluid intake to dilute urine and prevent sediment formation
what dietary restrictions should gout patients follow?
- a strict, low-purine diet
- avoid organ meats
- shellfish
- oily fish with bones (i.e. sardines)
- red meat
- alcohol
an HIV patient with a CD4 count < 400 - 500 is a risk for what and should take which precautionary measures?
- spreading the infection
- practice safe sex: use a condom and water-based lubricants
an HIV patient with a CD4 count < 200 means what?
- considered AIDS at this point
- immunocompromised
a low Hgb and Hct may indicate what?
bleeding/blood loss
what is ESR and elevations indicate what?
erythrocyte sedimentation rate (ESR) -
- elevation indicates chronic inflammation along with c-reactive protein
what does a WBC > 10,000 indicate and what should be the first action by the nurse?
leukocytosis: infection
- perform thorough assessment looking for cut/site of infection
- purulent drainage, warm, red, erythema
elevated neutrophils indicate what?
early stage of bacterial infection
- they are responsible for phagocytosis
kaposi sarcomas are seen with what condition?
HIV
- purple lesions that affect the soft tissue
what is neutropenia and what precautions must be taken with these patients?
neutrophil < 1000
- avoid rectal temperature
- restrict visitors
- no fresh fruit/flowers
use contact precautions
- wear mask
Avoid rectal temp
what is thrombocytopenia?
platelet count <150,000
- usually patient’s on chemotherapy
what are thrombocytopenia patient’s at risk for?
prone to bleeding
- monitor urine and stool for occult blood
what are expected surgical site findings?
pain and serosanguinous drainage
what is the function of basophils?
release heparin and histamines during the early inflammatory response to increase permeability
what is the function of eosinophils?
destroy allergens (type 1 hypersensitivity rxns - rhinitis) and parasitic infections
where are T and B cells produced?
in the bone marrow
where does T cell mature?
in the thymus
where does B cell mature?
in bone marrow
which cells are primarily involved in antibody mediated immunity?
B cells
what type of precautions are required for a patient with MRSA?
contact precautions
what leads to MRSA?
unnecessary overuse of antibiotics
what is MRSA currently resistant to?
resistant to all beta-lactam antibiotics
- including penicillin, cephalosporins, and carbapenems
what is the preferred treatment for MRSA?
IV Vancomycin
what leads to VRE?
prolonged exposure to antibiotics
- vancomycin - resistant enterococci
clients on multiple antibiotics are at risk for what infection?
clostridium difficile (C-diff)
- antimicrobials suppress the normal flora and create an environment for C-diff to flourish
- the greater the number of antimicrobials, number of doses, and duration of administration - the higher the risk
what is the most effective way to prevent the spread of infection?
hand hygiene
- with C-diff must be soap and water
- sanitizers are ineffective
with a c-diff infection, what causes diarrhea?
the bacteria proliferate releasing toxins causing an inflammatory response in the colon
- which causes fluid to be secreted into the colon, resulting in diarrhea
- this increased BM frequency can result in dehydration
what is the common cause of Acinetobacter Baumanni Infection?
Ventilator - associated pneumonia
what are the first steps in sepsis treatment?
- assessment
- fluid bolus
- obtain blood cultures
- antibiotics
what vital signs and lab findings indicate a client most at risk for sepsis?
SBP < 90
HR > 100
WBC > 12,000 = septic shock
does a client with influenza require airborne precautions?
no droplet
how long are client’s with influenza infections for and when does viral shedding occur?
infections up to 7 - 10 days
virus shedding ends 2 - 5 after symptoms appear
does influenza require a cough to spread?
no, it is airborne
what are contraindications to the flu vaccine?
- pregnancy
- immunocompromised
- over 50 or under 2 are contraindications to the live attenuated influenza vaccine
- egg allergy is a contraindication to any influenza vaccine (not shellfish or nuts)
would patient with asthma benefit from the flu vaccine?
yes
- increased risk of respiratory complications
when are live virus vaccines contraindicated in HIV patients?
CD4 count < 200
in household members of someone with HIV
which vaccines are not live?
DTaP
HIB
Hepatitis B
what are first and second line defenses against infection?
- sneeze
- purulent drainage/neutrophils in a cut
- skin
- saliva
firs line:
- skin
- sneeze
- saliva
second line:
- purulent drainage/neutrophils in cut
which is an indication that the patient is experiencing a systemic response during an acute inflammatory response?
- pain
- fever
- edema
- drainage
fever
is the WBC or RBC count impacted by chronic inflammation?
- WBC increases with chronic inflammation
- RBC is not influenced by inflammation
- changes may be related to conditions affecting the bone marrow
what type of hypersensitivity reaction is allergic rhinitis and asthma?
Type 1
what type of hypersensitivity reaction is lupus, RA, and serum sickness?
Type III
what type of hypersensitivity reaction is a blood transfusion reaction and rH sensitization?
Type II
what type of hypersensitivity reaction is poison ivy, TB test, and a spider bite?
Type IV
s/s of anaphylaxis?
- bronchospasms
- tachypnea
- tachycardia
- wheezing
- hypotension
- hypoxia
- goal SpO2 > 95%
what is the treatment for a patient with wheezing, pruritus, urticaria, and angioedema
for mild reactions:
- SC or IM epinephrine injection
- 0.3 - 0.5mL of 1:1000 to constrict blood vessels
- increase BP
- improve CO
why are older adults more prone to infection, cancer, and autoimmune diseases?
- increase number of autoantibodies
- decreased production of antibodies
how does protein deficiency impact older adult immune system?
- decreased immunity
- cellular immunity
- phagocyte activity
- complement ability
risk factors of impaired immunity?
- old age
- chronic diseases
- certain medications such as prednisone
breast feeding is an example of which type of immunity?
natural passive
what disease impacts joints bilaterally, morning stiffness, and popping/clicking in the joints?
RA
what questions should you ask an older adult to evaluate their immune system?
- nutritional status
- medications
- chronic illnesses
- social history
- vaccination status
wat foods should an older adult consume to increase protein intake?
mainly animal products:
- beef
- chicken
- fish
- milk
what chronic disease puts patients at risk for impaired immunity, eye damage, and CV damage?
diabetes
what diseases are females at an increased risk for?
RA and lupus
what is the progression of breath sounds with anaphylaxis?
- wheezing, stridor, then nothing
- if epi administration was effective - you will hear normal lung sounds
what type of isolation is required for patients with MDR?
contact isolation
what conditions does a patient have if they are on multiple antibiotics and start to have loose, watery stools?
C-diff
- must go in contact isolation
is the varicella vaccine live?
yes
a patient with what condition can have kidney damage and urine output < 30mL/hr?
lupus
True or False:
T cells work with B cells to protect the body?
True
