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Nursing School WCU > Lecture Final Micro > Flashcards

Lecture Final Micro Flashcards

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1
Q

Using hot water and soap…what type of treatment corresponds to….

A

Washing dishes in the dishwasher with detergent and hot water is a ____ process.
ANS: Disinfecting

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2
Q

What are disinfectants and their characteristics?

A

Which of the following statements is TRUE of disinfectants?
ANS: they are used on inanimate surfaces.

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3
Q

What is Sanitization, and mode of action of most common agents?

A

You notice a sign in a public restroom that states “Sanitized for your safety.” This means
ANS: methods of disinfection that meet minimum standards of microbial removal have been used.

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4
Q

What is pasteurization, and how is it attained? Give examples.

A

Which of the following describes flash pasteurization?
ANS: heating at 72 degrees C for 15 seconds

Which of the following is an example of pasteurization?
ANS: Heat is used to kill potential pathogens in apple juice.

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5
Q

What are aseptic, sterility, and sanitation, and how do we attain them?

A

Aseptic means
ANS: Free of pathogens

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6
Q

What are incineration, sanitization, degerming, disinfection, and sterilization?

A

The process of incineration is used for
ANS: sterilization

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7
Q

Targets of antimicrobial agents on microorganisms.

A

Antimicrobial agents that damage nucleic acids also affect
ANS: protein synthesis

A chemical agent that dissolves lipids can damage
ANS: cells and enveloped viruses

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8
Q

Target of Beta-lactam and cephalosporin antibiotics.

A

Beta-lactam antibiotics such as penicillins, have an effect on which of the following types of cells?
ANS: Bacterial cells

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9
Q

Primary advantage of semisynthetic drugs.

A

Which of the following is a primary advantage of semisynthetic drugs?
ANS: they are more effective than the unmodified natural antibiotics

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10
Q

Drug synergy, cross-resistance, anti-metabolism, chemotherapy, selective toxicity.

A

The cooperative activity of drugs such as beta-lactam antibiotics and clavilanic acid, a beta-lactamase inhibitor, is known as
ANS: Synergism

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11
Q

Effect of antibiotics on the bacterial cell wall.

A

The mechanism of action of the antibiotic vancomycin is
ANS: inhibition of cell wall synthesis

Which of the following drugs specifically targets cell walls that contain mycolic acid?
ANS: isoniazid

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12
Q

Azol drugs and their effect on cell membranes.

A

Azole drugs are antifungal medications that disrupt fungal cell membranes by inhibiting the synthesis of ergosterol, a key component of these membranes. By targeting the enzyme lanosterol 14α-demethylase, azoles prevent ergosterol production, leading to increased membrane permeability and cell damage. There are two main types: imidazoles (e.g., clotrimazole) and triazoles (e.g., fluconazole). While effective against many fungi, resistance and side effects, including liver toxicity and drug interactions, are significant clinical considerations.

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13
Q

Drugs that bind to the isoleucyl-tRNA synthetase and their action.

A

Drugs like mupirocin and tavaborole bind to isoleucyl-tRNA synthetase, inhibiting this enzyme’s function. This prevents the attachment of isoleucine to its tRNA, disrupting protein synthesis. Mupirocin is used topically for bacterial infections, especially MRSA, while tavaborole treats fungal nail infections. By halting protein production, these drugs effectively stop the growth and survival of bacteria and fungi.

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14
Q

Sulfonamide and targets.

A

A drug is structurally similar to PABA and inhibits folic acid synthesis. It is most likely a(n)
ANS: Sulfonamide

Which of the following steps in the folic acid synthesis pathway is specifically inhibited by sulfonamides?
ANS: the conversion of PABA to dihydrofolic acid

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15
Q

Quinolones and Fluoroquinolones target

A

Which of the following drugs inhibits nucleic acid synthesis specifically in most bacteria?
ANS: fluoroquinolones

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16
Q

Plecoranil and targets.

A

pleconaril dramatically reduced virus levels in target tissues of coxsackievirus serotype B3 strain M-infected animals. Pleconaril represents a promising new drug candidate for potential use in the treatment of human enteroviral infections.

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17
Q

What is an ideal antimicrobial agent?

A

Antimicrobial agents that damage nucleic acids also affect
ANS: protein synthesis

Which of the following antimicrobial agents is the most toxic to humans?
ANS: ethylene oxide

Which of the following is NOT a desirable characteristic of an ideal antimicrobial agent?
ANS: it only arrests growth of vegetative cells

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18
Q

The Epsilon test (E-test) and the Minimal Inhibitory Concentration

A

Etest is a quantitative technique for determining the antibiotic sensitivity and minimum inhibitory concentration (in μg/mL) of some bacteria

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19
Q

Consequences of the alteration of the normal microbiota.

A

Which of the following can result when antibiotic therapy disrupts the normal microbiota?
ANS: both pseudomembranous colitis and thrush

Disruptions of the normal microbiota can result in infections caused by which of the following microbes?
ANS: both Candida albicans and Clostridium difficile

Secondary infections that result from the killing of some of the normal microbiota are called
ANS: superinfections

Normal microbiota may cause disease if conditions change in the body
ANS: TRUE

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20
Q

Staphylococcus aureus as a primary and secondary pathogen.

A

Staphylococcus aureus as a Primary Pathogen:

Causes Disease in Healthy Individuals: Skin infections (boils, impetigo), pneumonia, sepsis, endocarditis, toxic shock syndrome.
Mechanism: Utilizes toxins, enzymes, and adhesion factors to invade and cause disease.
Staphylococcus aureus as a Secondary Pathogen:

Infects When Predisposing Factors Exist: Hospital-acquired infections (surgical sites, catheters), infections in chronic disease patients (diabetes, HIV), secondary infections post-viral illness (post-influenza pneumonia).
Mechanism: Exploits weakened immune defenses or compromised barriers to establish infection.
Staphylococcus aureus can cause infections both in healthy individuals and those with predisposing factors.

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21
Q

Normal fungal members of the normal human microbiome

A

Which of the following is NOT considered a member of the normal human microbiota?
ANS: Microsporum

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22
Q

Toxins of the Gram-negative bacteria.

A

A toxin common to all Gram-negative bacteria is
ANS: lipid A

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23
Q

Virulence factors of S. aureus and their action.

A

Among the virulence factors produced by Staphylococcus aureus are hemolysin, coagulase, hyaluronidase, and enterotoxin. Which of these factors contribute to the ability of S. aureus to invade the body?
ANS: hyaluronidase

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24
Q

Phases of an infectious and disease process.

A

Which of the following stages of an infectious disease is the most severe?
ANS: the illness period

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25
Q

Vehicles of microbial transmission.

A

Which of the following is transmitted by the parenteral route?
ANS: yellow fever

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26
Q

What is a mechanical vector, examples.

A

Which of the following is considered a mechanical vector transmission?
ANS: cockroach transmission of Shigella

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27
Q

Disease signs and symptoms.

A

Which of the following is a sign of a disease?
ANS: Fever

Which of the following is a symptom of a disease?
ANS: Fatigue

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28
Q

Examples of symptoms.

A

Symptoms are
ANS: subjective characteristics of a disease that only the patient can feel

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29
Q

Pathogenesis and virulence factors of Neisseria gonorrhea.

A

A strain of Neisseria gonorrhea has a mutation which has caused it to lose the ability to produce fimbriae and become less virulent as a consequence. What function has this pathogen lost?
ANS: the ability to adhere to cells of the body

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30
Q

Phases of the disease process

A

Which of the following stages of an infectious disease is the most severe?
ANS: the illness period

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31
Q

What is iatrogenic, exogenous, opportunistic, endogenous, subacute

A

Diseases that are induced by modern medical procedures are referred to as
ANS: Iatrogenic

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32
Q

What are the first and second lines of defense against microbes?

A

Cells of the second line of defense called ____ recognize and kill virus-infected cells.
ANS: NK Cells

Which of the following cells is a component of the body’s first line defense?
ANS: goblet cell

The first and second lines of defense against microbial invasion are part of
ANS: innate immunity

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33
Q

The second line of defense against invading microbes.

A

The second line of defense against invading microbes includes
ANS: phagocytic white blood cells

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34
Q

Response to specific pathogens with subsequent exposure

A

Response to specific pathogens that can improve with subsequent exposure is
ANS: the third line of defense

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35
Q

What is fever and its functions?

A

Fever is beneficial during viral infection because the higher temperature
ANS: increases the effectiveness of interferons.

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36
Q

Granulocytes and agranulocytes

A

Which of the following leukocytes are called agranulocytes because of the absence of granules in their cytoplasm revealed by basic or acidic dyes?
ANS: lymphocytes

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37
Q

Connection between macrophage and monocytes.

A

Which cell becomes a macrophage when leaving the bloodstream?
ANS: monocyte

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38
Q

Antibacterial chemicals in tear fluid.

A

What antibacterial chemical is present in tear fluid?
ANS: lysozyme

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39
Q

Granulocytes and their function.

A
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40
Q

Antimicrobial peptides on skin and mucosal membranes.

A

Antimicrobial peptides called ______ are secreted in sweat and damage bacteria and fungi.
ANS: dermcidins

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41
Q

Third line of defense and difference 1st and 2nd lines of defense.

A

Which of the following characteristics of the third line of defense makes it significantly different from the second line?
ANS: the response is specific to a single antigen

42
Q

Adaptive immunity components and their action.

A

Adaptive immunity is sometimes also called acquired immunity. Which of the following statements provides a basis for the alternative name?
ANS: to become activated, lymphocytes require exposure to the epitope for which they are specific.

43
Q

Cells of adaptive immunity.

A

The white blood cells primary responsible for adaptive immunity are
ANS: B lymphocytes and T lymphocytes

44
Q

Reaction of the body to deep wound infections.

A

The body’s reaction to deep wound infections includes:

Inflammatory Response: Redness, heat, swelling, and pain due to increased blood flow and immune cell activity.
Immune Cell Recruitment: Neutrophils and macrophages arrive to kill and remove pathogens.
Pus Formation: Accumulation of dead cells and bacteria.
Systemic Response: Fever and swollen lymph nodes to help fight infection.
Tissue Repair: Fibroblasts produce collagen, new blood vessels form, and skin cells cover the wound.
Chronic Infection/Sepsis: If untreated, can lead to abscess formation or systemic infection.

45
Q

Antibody types and what they do.

A

Which of the following best describes IgM antibodies?
ANS: they are the most common type of antibody in the blood during the initial stages of an immune response.

IgE antibodies are best described as
ANS: a cause of basophil and eosinophil degranulation

IgG antibodies can carry out all five antibody functions
ANS: TRUE

The most prevalent antibody class in the blood is
ANS: IgG

Secretory IgA antibodies are unique because they
ANS: are connected with J chains and short polypeptides to form dimers

46
Q

Agglutinating antibodies.

A

The concentration (or titer) of antibody to a specific antigen can be determined using a ____ test.
ANS: Agglutination

Agglutination tests are used to detect soluble antigens
ANS: FALSE

Which of the following function in agglutination?
ANS: IgA and IgG antibodies

A serological test that involves the clumping of antigen and antibody is the ____ test.
ANS: agglutination

In agglutination, several immunoglobulin (antibody) molecules bind two or more microbial cells together, causing them to clump.

47
Q

What are cytokines, and how do they work?

A

Which of the following cytokines act as a signal between leukocytes?
ANS: Interleukins

Cytokines are soluble regulatory proteins that act as intercellular signals and include substances such as interleukins, interferon, and growth factors.
ANS: TRUE

Which of the following cytokines promotes the development of a cell-mediated immune response?
ANS: IL-12

48
Q

Clonal selection theory and the development of B and T-lymphocytes. Where it takes place.

A

How is the development of autoimmunity normally prevented?
ANS: Clonal deletion of T Cells, lack of necessary cytokine signals, and regulatory T Cell suppression prevent activation of autoreactive T cells.

Clonal deletion of developing T lymphocytes takes place in which location(s) in the body?
ANS: the thymus

49
Q

Enhanced or boosted immune response. How does it work?

A

Enhanced immune responses to subsequent exposures to an antigen to which the body has already been exposed are known as ____ responses.
ANS: memory

50
Q

Immunity development after contact with an infectious agent

A

What type of immunity is produced by the body when a person contracts a disease?
ANS: naturally acquired active immunity

51
Q

The skin is an effective barrier.

A

The skin is an effective barrier against invading microbes because
ANS: the outer layers are dead and covered in salt

52
Q

Leptospirosis and animals.

A

Which of the following is commonly the source of leptospirosis?
ANS: infected animal urine

During the spring calving season, a ranch hand begins to run a fever and feel nauseous and achy. After he develops a headache and vomiting, he goes to a clinic. A microscopic exam of a urine sample reveals long thin microbes which move very rapidly in a corkscrewing pattern. The man may have contracted
ANS: leptospirosis

53
Q

Normal flora of the human skin.

A

Normal skin microbiota are able to grow on the skin because they thrive in the presence of
ANS: Sebum and Salt

54
Q

Virulent strains of Staphylococcus aureus.

A

Virulent strains of Staphylococcus aureus can resist penicillin because they produce
ANS: beta-lactamase

55
Q

Enzyme as a virulence factor in S. aureus and phagocytosis evasion.

A

Enzyme as a Virulence Factor:
Coagulase:

Function: Converts fibrinogen to fibrin, forming clots around bacteria.
Role: Shields S. aureus from the immune system, aiding in evasion and infection persistence.
Evasion of Phagocytosis:
Protein A:

Function: Binds to Fc region of antibodies.
Mechanism: Prevents opsonization and phagocytosis.
Capsule:

Function: Polysaccharide layer.
Mechanism: Inhibits immune cell recognition and engulfment.
Staphylococcal Complement Inhibitor (SCIN):

Function: Inhibits complement system.
Mechanism: Reduces opsonization and membrane attack complex formation.
Clumping Factor (Clf):

Function: Binds fibrinogen/fibrin.
Mechanism: Promotes aggregation, aiding evasion.
These factors enable S. aureus to evade immune defenses and enhance its ability to cause infections.

56
Q

What is Impetigo and its causes?

A

Impetigo can be caused by
ANS: Both Staphylococcus aureus and Streptococcus pyogenes

57
Q

Cat scratch and course of infection.

A

The syndrome known as cat scratch disease results when ____ is introduced into a wound
ANS: Bartonella

58
Q

Anthrax origin, name, cause, types.

A

Anthrax derives its name from which of the following aspects of the disease?
Ans: the appearance of eschars on the skin

59
Q

Pseudomonas as a resistant microbe, mechanism of resistance.

A

The resistance of Pseudomonas to a wide variety of antimicrobial drugs is due, in part, to its ____.
ANS: ability to pump drugs out of the cell.

60
Q

“Ringworm” how is caused and by what type of microbe.

A

“Ringworm” is caused by
ANS: dermatophytes growing in the upper dead tissue layers of the skin.

61
Q

Gram-negative diplococcus pathogens.

A

The presence of Gram-negative diplococci in pus from an inflamed penis is diagnostic for infection by
ANS: Neisseria gonorrhoeae.

62
Q

Gram-positive diplococcus pathogens

A

The Gram-positive diplococcus ________ is commonly found in the pharynx but may invade the central nervous system inside cells where it survives after endocytosis.
ANS: Streptococcus pneumoniae

63
Q

Food contamination, sources, and meningitis.

A

Contaminated food is the source of ________, which causes meningitis in the elderly and susceptible persons.
ANS: Listeria monocytogenes

64
Q

Epidemic bacterial meningitis.

A

The type of bacterial meningitis that becomes epidemic among young adults is caused by
ANS: Neisseria meningitis

65
Q

Foodborne botulism.

A

Which of the following is TRUE of foodborne botulism?
ANS: It is an intoxication disorder

66
Q

Symptomology of tetanus: can you recognize someone with tetanus?

A

How does tetanospasmin affect motor control?
ANS: it blocks the release of inhibitory neurotransmitters in the CNS

A baby arrives at an emergency room suffering from violent muscles spasms and difficulty breathing. The baby’s body is so rigid a proper exam is difficult, but the staff note the baby is only a few weeks old and the umbilicus has not healed properly. The signs are consistent with which of the following diseases?
ANS: Tetanus

67
Q

What is the nature of the Tetanus vaccine or toxoid?

A

Tetanus vaccine contains
ANS: inactivated tetanospasmin

68
Q

How is the Poliovirus transmitted?

A

Poliovirus is most often transmitted via
ANS: contaminated water

69
Q

Zoonotic infections and their transmission.

A

Zoonosis known as ____ is transmitted to humans by fleas.
ANS: Plague

The zoonosis _____ is acquired by skin contact and becomes a systemic infection.
ANS: leptospirosis

70
Q

African sleeping sickness vector and agent.

A

The presence of the pathogen in the blood called ___ is a defining feature of African sleeping sickness.
ANS: parasitemia

71
Q

Heart circulation, to the heart and away from the heart.

A

Blood returns to the heart from the lungs through the pulmonary ____.
ANS: Veins

Which of the following vessels carries blood from the heart to the rest of the body?
ANS: Aorta

The chambers and valves of the heart are lined by the
ANS: endocardium

Blood returning from circulation through the body first enters the
ANS: right atrium

72
Q

What is bacteremia, lymphangitis, toxemia, lipidemia, and viremia?

A

Infection of lymphatic vessels is known as
ANS: Lymphangitis

73
Q

What is severe bacteremia and its causes

A

A blood sample from a patient is examined on a microscope. Bacterial cells are detected in the sample. The patient has
ANS: bacteremia

74
Q

Toxic shock syndrome (TSS).

A

Toxic shock syndrome (TSS) is associated with
ANS: both staphylococcus aureus and streptococcus pyogenes

75
Q

Recognizing septicemia, plague, Lyme disease, brucellosis, infectious mononucleosis

A

A person is brought to the emergency room with constant high fever, extensive edema, low blood pressure, and petechiae. From which of the following may the person be suffering?
ANS: Septicemia

76
Q

Francisella tularensis transmission.

A

Which of the following is/are a reservoir for Francisella tularenis?
ANS: Rabbits and ticks

77
Q

Fleas as pathogen carriers, which are pathogens.

A

The plague is transmitted by ____.
ANS: Fleas

The normal habitat of ________ is rodents, but humans bitten by fleas carrying the pathogen have fever, severely inflamed lymph nodes, and headache. Later, areas of black, necrotic tissue may develop.
ANS: Yersinis pestis

78
Q

Yersinia pestis infection, stages, and means of infection.

A

Which of the following is a characteristic of Yersinia pestis infections?
ANS: buboes

79
Q

Ticks as infectious disease vectors.

A

Lyme disease is vectored by ticks.
ANS: TRUE

A young man living in the Southeastern U.S. is an avid outdoorsman and has a history of tick bites. Blood tests show that he has leukopenia… He may have contracted
ANS: ehrlichiosis

It is the ____ stage of the tick genus ixodes that most often transmits Lyme disease to humans
ANS: nymphs

80
Q

What is Yellow Fever? Etiology.

A

A few days of fever with vomiting followed by high fever, jaundice, and “black vomit” are characteristics of
ANS: yellow fever

81
Q

The respiratory systems and major components.

A

Major Components of the Respiratory System:
Upper Respiratory Tract:

Nose and Nasal Cavity: Filters, warms, and humidifies air.
Pharynx (Throat): Passageway for air, food, and liquids.
Larynx (Voice Box): Contains vocal cords and protects the trachea.
Lower Respiratory Tract:

Trachea (Windpipe): Connects larynx to bronchi.
Bronchi: Main airways into the lungs.
Bronchioles: Smaller airways within the lungs.
Alveoli: Tiny air sacs for gas exchange.
Lungs:

Lobes: Right lung (3 lobes), left lung (2 lobes).
Pleura: Membrane surrounding the lungs.
Diaphragm:

Muscle below the lungs essential for breathing.
These components work together to facilitate breathing and gas exchange.

82
Q

Inflammation of the pharynx and tonsilitis causes.

A

Inflammation of the pharynx with pus-filled abscesses and swollen tonsils is known as
ANS: streptococcal pharyngitis (strep throat)

83
Q

Opportunistic pathogen of the nasal cavity.

A

Which of the following is an opportunistic pathogen commonly present in the nasal cavity as a member of the microbiota?
ANS: Staphylococcus aureus

84
Q

Lancefield streptococcus classification.

A

The designations “group A” used to help classify streptococcus pyogenes, refers to this bacterium’s
ANS: Lancefield antigen

85
Q

Group A streptococci virulence factors.

A

Group A streptococci produce _____ which breaks down blood clots, allowing the bacteria to spread.
ANS: streptokinase

86
Q

Streptococcus pyogenes virulence factors.

A

Which of the following Streptococcus pyogenes virulence factors kill leukocytes and erythrocytes?
ANS: streptolysins

87
Q

Streptococcus pyogenes virulence factors on leukocytes.

A

Which of the following Streptococcus pyogenes virulence factors kills leukocytes and erythrocytes?
ANS: Streptolysins

88
Q

Diphtheria toxin mode of action.

A

Diphtheria toxin kills cells by interfering with which of the following processes?
ANS: Protein synthesis

Which of the following statements is TRUE concerning diphtheria?
ANS: The signs and symptoms of the disease are directly caused by a bacterial toxin

89
Q

Major agents that cause pneumonia.

A

The majority of cases of pneumonia are caused by
ANS: Streptococcus pneumoniae

90
Q

Types of antibodies and their functions

A

Types of Antibodies and Their Functions:
IgG (Immunoglobulin G):

Function:
Provides long-term immunity and memory against pathogens.
Neutralizes toxins and viruses.
Opsonizes pathogens for phagocytosis.
Activates complement system.
Notes: Most abundant antibody in blood and extracellular fluid. Can cross the placenta to provide passive immunity to the fetus.
IgA (Immunoglobulin A):

Function:
Protects mucosal surfaces (e.g., respiratory, gastrointestinal tracts).
Neutralizes pathogens and toxins.
Prevents pathogen adherence to mucosal cells.
Notes: Found in mucosal secretions (saliva, tears, breast milk), blood, and lymph.
IgM (Immunoglobulin M):

Function:
First antibody produced in response to an infection.
Effective at forming antigen-antibody complexes.
Activates complement system.
Notes: Exists as a pentamer in blood, making it highly effective at cross-linking antigens.
IgE (Immunoglobulin E):

Function:
Binds to allergens and triggers histamine release from mast cells and basophils.
Plays a key role in allergic reactions.
Provides defense against parasitic infections.
Notes: Found in low concentrations in the blood, but significant in allergic responses and asthma.
IgD (Immunoglobulin D):

Function:
Functions mainly as a receptor on B cells for antigen recognition.
Involved in initiating B cell activation and differentiation.
Notes: Present in low concentrations in the blood and primarily found on the surface of immature B cells.
Summary:
IgG: Long-term immunity, neutralization, opsonization, complement activation.
IgA: Mucosal immunity, neutralization, prevents pathogen adherence.
IgM: Initial immune response, antigen complex formation, complement activation.
IgE: Allergic reactions, defense against parasites.
IgD: B cell receptor, B cell activation.
Each type of antibody has a specific role in the immune response, helping to protect the body against various pathogens and foreign substances.

91
Q

Mycoplasma pneumoniae and what it causes.

A

The microbe which causes primary atypical pneumonia is
ANS: Mycoplasma pneumoniae

Which of the following statements is TRUE regarding infection with Mycoplasma pneumoniae?
ANS: the causative agent attaches to ciliated cells in the respiratory tract.

92
Q

Porphyromonas gingivalis and what it causes.

A

Porphyromonas gingivalis contributes to the development of
ANS: Periodontitis

93
Q

Peptic ulcers and their microbial etiology.

A

Most peptic ulcers are the result of colonization of the stomach by
ANS: Helicobacter pylori

94
Q

Helicobacter pylori in surviving stomach acid.

A

Urease is an important virulence factor of which of the following?
ANS: Helicobacter pylori

Helicobacter pylori colonizes the _____ and can cause severe inflammation and tissue erosion.

95
Q

Vibrio cholera toxins.

A

The virulence factor of Vibrio cholera, is primarily responsible for the signs and symptoms of cholera, is
ANS: its ability to produce a potent exotoxin

96
Q

pH of the various parts of the body.

A

The normal pH of the vagina is
ANS: pH 4.5

97
Q

Functions of the prostate.

A

The prostate produces
ANS: semen

98
Q

UTI infecting agents.

A

Pseudomonas species are occasional causes of
ANS: Urinary Tract Infections

99
Q

Bacterial zoonosis and mode of entry.

A

Rabies is a rare zoonosis in humans but common in many other species of mammal
ANS: TRUE

The zoonosis known as ____ is transmitted to humans by fleas
ANS: plague

The zoonosis ____ is acquired by skin contact and becomes a systemic infection
ANS: leptospirosis

100
Q

Systemic infection by Streptococcus and formation of antigen-antibody complexes.

A

The disorder ________ is a complication of systemic infections with Streptococcus in which antigen-antibody complexes form in the blood and get trapped in the kidneys.
ANS: glomerulonephritis

Nursing School WCU (36 decks)

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