GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+, Exams of Nursing

Download GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ and more Exams Nursing in PDF only on Docsity! GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ • Mr. Davidson is a 24-year old boxer. He had a boxing game and received with a nose injury. Due to heavy nosebleed, he was transferred to ER. Health Assessment and Physical Exam: Diagnostic Test: Deviated septum is observed. X-ray is done to confirm the diagnosis. • Patient is alert and oriented. He didn't lose his consciousness. The patient reports severe nose pain. No other symptoms. • Nursing Care: • What should be your highest priority when you plan the care of this patient? o Vent airway, BCs • Which position should you assist the patient to and why? o Up right position, head slightly forward • How do you differentiate between anterior nasal bleeding and posterior nasal bleeding? o Posterior: secondary to hypertension, older people, coughing, more dangerous, back of throat o Anterior: stops spontaneously, not life threatening, able to see • What are some of the nursing interventions that can help control the bleeding of this patient? Provide rationale. o High fowlers, pinch nose, head tilt forward, acetaminophen, nasal sponges, nasal packing, medication for pain, Tylenol (no NSAIDS) GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ • What is the appropriate way to apply pressure to stop the epistaxis? How and for how long? o Pinch nose against septum 10-15 mins, up right, lean forward, ice • Would you insert gauze into the bleeding nostril in this case? Why? o NO because patient has a fx. If stops in 10-15 mins then no gauze • Considering the bleeding, what medications would be contraindicated? o NSAIDS, (aleve, advil, ibuprofen) anticoagulants (warfarin, heparin, Lovenox) ▪ Heparin-IV, SC Lab: aPPT Need: sulfate ▪ Coumocin- PO Lab: PT, INR Need: vit K ▪ Lovenox- • If you notice a clear liquid draining from the patient's left ear, what should you do next? o Worried about CSF from skull fx, check fluid for glucose, send to lab • What do you expect the vital signs of this patient to be? Explain. o Increased HR, high RR, increase BP patient is in distress and anxious • The ENT specialist applies nasal ointment that includes topical Lidocaine and epinephrine. What are the indications and desired outcomes of these two agents? o Lidocaine pain, epi is vasoconstrictor • The bleeding continues, so the ENT decides to use a Pledget (nasal tampon) impregnated with cocaine. Why cocaine? o Cocaine- potent anesthetic and vasoconstrictor GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ allergic reaction and the commonly prescribed medications. o Histamine- antihistamines (counteract histamines released) • What is the indication, mechanism of action, desired outcome, side-effects, and adverse effects of 1st- generation antihistamines? What is the major advantage of 2nd-generation antihistamines compared with 1st-generation antihistamine? Mention one 1st-generation antihistamine agent and 2nd- generationantihistamine agent. ▪ 1st gen- Benadryl (diamahydramine) ▪ Side effect: drowsiness –crosses blood brain barrier, sedation effect on brain ▪ Nursing consideration: no driving ▪ 2nd Gen- Zyrtec, Claritin, allegra ▪ Pros: non-sedative, ▪ Con: not as strong as 1st • How can the patient manages the dry mouth/mucosa results from antihistamines? o Ice chips, hydration • Flunisolide spray, an intranasal corticosteroid, is prescribed for Mrs. Jones. For the best results, when should Mrs. Jones start using Flunisolide? o Couple weeks before allergy season o Take every day, no prn • Mrs. Jones says "I should take Flunisolide when I need"? How should you responds? o False, need a few weeks to kick in GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ • Mrs. Jones says "Flunisolide relieves symptoms within minutes". How should you respond? o no • Mrs. Jones asks "I usually get a sinus infection once a year, should I continue flunisolide if I get a sinus infection or quit?" How should you responds? o Keep taking • In October, Mrs. Jones' symptoms become worse and Singulair (monteLUKAST), a leukotriene receptor antagonist inhibitor was added. Before Mrs. Jones can start using Singulair, what should the prescriber check first? o Liver function- AST and ALT labs • It is safe for Mrs. Jones to use Singulair, what time of the day should she take it? o evening • Few months after using Singulair, Mrs. Jones calls and reports that her eyes are "turning yellow". What should you tell her? o Stop med, liver damage • Due to some life events, Mrs. Jones develops depression. Phenelzine (Nardil), an monoamine oxidase inhibitor (MAOI), was prescribed for her. How will Nardil affect the allergy medications of Mrs. Jones? GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ o Interacts with other medications, stop allergy med • Mrs. Jones tells you that her mother-in-law has developed nasal congestion and she is going to get her Sudafed (pseudoephedrine) over-the-counter (OTC). Sudafed would be contraindicated if the patient has what medical conditions? o Table 26-2: Heart issues, hypertension, • Phenylephrine (Neo-Synephrine), an alpha-1 adrenergic agonist topical decongestant, is prescribed to use PRN. What cautions regarding the use of this decongestant should you include in the teaching plan? o Do not take more than 3 times daily, able to get rebound congestion • Mrs. Jones tells you that her pulmonologist mentioned to her a therapy called "immunotherapy" and ask you to tell her more about. o Intro allergen to body slowly so get get used to allergen (desensitize) o Allergy shots • Provide patients with education based on table 27-1. • KNOW!!! Antihistamines, singulair, corticosteroids, decongestants o Know typical med, generic and brand name, nursing consid, side effects, who cant use # 3: Acute Viral Rhinitis (Common Cold) • Mr. Richards has developed a common cold. He tells you that last week he worked 7 days in a row 14 hours a day. He asks you if there was a connection between working "to much" and getting the cold. What should your response be? o Yes, stress increases chances of getting sick • What are the latent viruses? and where do they live? GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ o false • The 45 years old say "by receive the vaccine, I will NOT get the flu this year". Respond. o False, not all viruses are covered with the vaccine • To screen your patients to contraindication, what should you assess for? o Allergies to eggs, severe rx before, Guillain-Barré syndrome • Antivirals like amantadine (Symmetrel) and rimandtadine (Flumadine) are routinely given to treat influenza infection. True/False? o Only prescribed within first 48 hours, only prevent virus from replicating # 5: Sinusitis Chris is a 27-year old who is a professional swimmer. He has developed a bacterial sinusitis. (inflammation of sinuses blocking mucus from draining) • What are some of the risk factors for acute sinusitis? o URI, common cold, deviated septum, foreign bodies • Since Chris is having a bacterial infections, what are some of the classical symptoms that he will experience? o Fever, TTP face, mucus, purulent drainage, headaches, malaise • As a bacterial infection, it should be treated with antibiotics. What are the guidelines for selecting antibiotics? o Obtain culture, choose correct medication o If symptom less than 10 days, no meds GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ o If more than 10 days, choose amoxicillin. If does not work choose broader spectrum med. • The first line of choice to treat bacterial sinus infection is augmentin. o Amoxicillin and Clavulanic acid • What instructions regarding hydration should you give for patients with respiratory infections? o Hydrate, warm compress, sleep head elevated, hot shower, humidifier # 6: Acute Pharyngitis • Susan is a 19-year old freshman student presents to APU health center complaining of "scratcy throat". Through examination, acute pharyngitis is suspected. o Most pharagytis are virus! • The most common bacteria that causes pharyngitis is Group a Beta hemolytic streptococcus. • To confirm or rule out strep infection, what is the test of choice? o Strep test/culture • The presence of patchy yellow exudates supports the diagnosis of bacterial infection. True/False? • What are the complication of inadeuate treatment of strep pharyngitis? o Rheumatic fever, cardiovascular issues • Since acute pharyngitis is contagious, provide this patient with instructions about infection control. o Complete all meds, first 2 days you are very contagious after you are not contagious, don’t share GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ • Are antibiotics indicated in this case? o Penicillin, yes, yellow exudate and swollen tonsils • To prevent throat irritation, what kind of food should the patient ingest o Bland, warm or cool food, liquids, humidifier, avoid spicy or citrus # 7: Laryngeal Cancer Mr. Ghali is a 63-year old who has been diagnosed with laryngeal cancer. • There are some of the risk factors of laryngeal cancer? o • What is hoarseness and what it is relation to larynx problem? • In the physical exam report, you read "leukoplakia and erythroplakia". What are these? • Explain the TNM classification. o Typical staging o T (tumor size, damage) N (lymph nodes involved) Metastasis (spread to other tissue) o Stage 1-4 ▪ 1-2 can be cured ▪ 4 no cure, improve quality of life • What is the mechansim of action of radiotherapy, chemotherapy, and surgical therapy in case of layngeal cancer? o Surgical- remove tumor, o Chemo- use meds to kill cancer, IV or PO, need special certification to give chemo, GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ inactive TB? Why Mr.B's inactive TB became active? • Active TB - Positive TB test with symptoms present. Highly infectious. • Inactive TB - Positive TB test indicating that an individual has the bacteria in their system, but no symptoms are present. 5-10% of those with a positive TB test will go on to develop the disease at some point in their life. Not infectious. • Reinfection can occur when the patient becomes immunocompromised. Mr. B's Physical Exam Findings On exam, Mr. B appeared to be chronically ill and wasted. Cavernous breath sounds are heard over the right apex. 4. The MD suspects TB and orders a series of tests. Place the interventions in the order that they should be performed. 1. Perform a PPD intradermal skin test 2. Have a CXR performed 3. Institute airborne precautions 4. Obtain sputum culture 5. Notify the Department of Health 5. After the PPD skin test. The result of Mr. B will be considered positive if, after 48-72 hours, he develops an induration that measures over mm? What is the rationale? Think from different patient populations. • Mr. B is homeless and therefore categorized in the “at risk” population. In addition, based on the history he provided, he is suspected to be immunocompromised. Those who are immunocompromised have developed a decreased response to tuberculin, so smaller indurations are graded as positive. Therefore, if the induration measures over 5mm, Mr. B tests positive for the PPD test. 6. How to conduct a PPD skin test? route? read time window? how to interpret? Clinical significance? False positive in what kinds of populations? • Intradermal injection of 0.1 mL tuberculin in ventral side of forearm. Patient must wait a read time window of 48-72 hours before having the test read. If the injection has a reaction, it will show an “induration” at the site, described as a GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ hardened, raised (maybe swollen) bump, the diameter of the induration is measured and graded according to the patient’s risk-level. o Healthy, no-risk → positive if induration > 15mm o Immune but high-risk (IV drug users) → positive if induration >10mm o Immunocompromised → positive if induration > 5mm • An induration of a certain size means the patient is sensitive to tuberculin (have already encountered in and developed antibodies that react to it) testing positive, and likely has a TB infection. • A false positive PPD test can occur in low risk populations that have previously received a BCG (Bacillus Calmette Guerin) vaccine. 7. What's the isolation precaution for Mr. B? Criteria to discontinue isolation? Visitor education? • TB is an airborne precaution isolation. This means that the germs are so small that they can travel through the air and affect you. People with TB need to be in a negative pressure room. The patient should wear a mask. The staff who enter the room need to wear a fitted N95 mask, a gown, and gloves. A patient could discontinue this isolation once there are no signs or symptoms of infection, and has 3 negative AFB smears. This can be confirmed by a chest x-ray and blood tests. Visitors should be limited, and if they do enter the room, they need to be informed of the risk. Immunocompromised people should not visit someone who is on airborne isolation. 8. What's the best time to collect sputum culture? Clinical significance? Protocol for sputum specimen collection? • Before collecting sputum, have the patient rinse his or her mouth out with water. It is best to collect specimen in the early morning before breakfast to get all of the overnight secretions in the sample. Collect sample from a coughing secretion (sputum only). • A sputum sample collection is clinically significant because it is the best way to diagnose active TB. You can also test the effectiveness of the medications you are taking by collecting a sputum sample daily to see is the infection is reducing. • Obtain doctor’s orders to collect the sample. Make sure the container that your patient will be spitting into is not contaminated. Collect the sample before administering any form of antibiotics. Protocol would be to adequately label the container to ensure that the sample is from the desired patient. A smear and culture will be done on the sample to determine the degree, or presence of infection. GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ • Need 3 consecutive negative sputum 9. What's the clinical significance of having CXR in Mr. B? What would you see on CXR on a confirmed TB patient? What diagnostic exams are used to confirm the diagnosis of active TB? • A chest x-ray is beneficial for this patient because TB usually resides in the lungs. Though the scan the doctor can visualize the infection. A CXR of an active TB patient should show consolidation in the lungs. The picture below shows what a positive chest x-ray for a patient with active TB would look like: • The TB skin test can show that a person has been infected with TB, but it does not tell whether the person has latent or active TB. The skin test can also be a false-positive. The blood test does the same, it only will show if the person has been in contact with the virus, not if it is latent or active. The chest x-ray and sputum culture will confirm active TB. Nursing Science: Pharmacological Considerations GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ What specific type of pneumonia is that? There are 5 types of pneumonia. Commonly seen pneumonias are community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP). Other types of pneumonia include aspiration pneumonia, necrotizing pneumonia and opportunistic pneumonias. These pneumonias are more rare than CAP and HAP. HIV induced pneumonia would be considered an opportunistic pneumonia. Specifically, pneumonia due to HIV is Pneumocystis Pneumonia (PCP), which is a fungal pneumonia. • 4. Cervical lymph nodes are normally not palpable. What will happen to lymph nodes in viral or bacterial infections? In viral or bacterial infections lymph nodes become enlarged by swelling, and therefore will become palpable. The reason for this is that there are many white blood cells in the lymph nodes that are used to fight off infections, so they become enlarged due to this response to infections. • 5. When you further assess the patient, you observed the following. What is that? Pathophysiology rationale? The following picture is showing clubbing. Clubbing is common in COPD patients. Clubbing indicates that the nails are not getting oxygen and is a sign of emphysema. -Due to chronic hypoxemia or chronic cyanosis Mr. A's Physical Exam Findings o The patient is an elderly man who appears tired haggard and GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ underweight. His complexion is sallow. He coughs continuously. Sitting in a chair, he leans to his right side, holding his right chest with his left arm. Vital signs are as follows: blood pressure 152/90, apical heart rate 112/minute and regular, respiratory rate 24/minute and somewhat labored, temperature 102.6 F. o Examination of the neck reveals a large, non-tender hard lymph node in the right supraclavicular fossa. o Both lungs are resonant by percussion with one exception: the right mid- anterior and right mid-lateral lung fields are dull. o Auscultation reveals bilateral diminished vesicular breath sounds. Bronchial breath sounds, rhonchi and late inspiratory crackles (are heard) in the area of the right mid-anterior and right mid-lateral lung fields. The remainder of the lung fields is clear. Nursing Science : Physiological Integrity • 6. The MD orders CBC with differentials. What would you find from CBC to confirm the diagnosis of pneumonia? What else lab results will you find from CBC? What are the normal ranges? From the CBC, results showing elevated white blood cells–particularly elevations in neutrophils and neutrophil band would help confirm a diagnosis of pneumonia. Other lab results that you would find from a CBC include red blood cell count, white blood cell count, hemoglobin, hematocrit, mean corpuscular volume (MCV: average volume of red cells), mean corpuscular hemoglobin (MCH: average amount of hemoglobin per red blood cell), mean corpuscular hemoglobin concentration (MCHC: the average concentration of hemoglobin in the cells), and platelet count. With differentials, each group of white blood cells is broken down into a percentage. Differentials give the percentages of: neutrophils and neutrophil bands, lymphocytes, monocytes, eosinophils, and basophils. Normal Lab Values: • HB: o 13.2-17.3 g/dL in males o 11.7-15.5 g/dL in females • Hct: o 39-50% males GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ o 35-47% females • WBC: 4-11x103 µL • Platelet: 150-400x103 µL • RBC: o male 4.3-5.7x106/µL o female 3.8-5.1x106/µl • MCV: 80-100 fL • MCH: 27-34 pg • MCHC: 32-37 % • Neutrophils: 50-70% • L: 20-40% • M: 4-8% • E: 0-4% • B: 0-2% • Neutrophil Bands: 0-8% GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ before a definitive diagnosis or causative agent is confirmed (this should be started as soon as CAP is suspected). Empiric antibiotic therapy is based on experience and knowledge of drugs known to be effective for the most likely causative agent (in this case Streptococcus pneumoniae). With CAP, the decision to treat the patient at home or in the hospital depends on the patient’s age, vital signs, mental status, presence of co-morbidities, and physiological condition. Treatment for HAP is initiated based on known risk factors, onset of pneumonia (early or late stage), and most likely causative organism (in this case E. coli, K. pneumoniae, A. species). Antibiotic therapy is adjusted once the causative agent is confirmed through sputum culture. • CXR: Right lower and middle lobe infiltrates, suggests pneumonia. • Sputum culture: Pending. • The diagnostic finding confirm the diagnosis of right lung pneumonia. The physician decides to admit Mr. A and orders the following: o 1.Bed rest; o 2. Specimens for C&S; o 3. Oxygen via nasal cannula; o 4. Administration of an antibiotic. Nursing Science : Management of Care • 10. What will be the isolation precautions for Mr. A? What kinds of patient you may place in the same room with Mr. A? Mr. A will be placed on isolation for droplet precautions, meaning that he can only be placed in the same room as other patients with pneumonia as well. All who enter the room must wear PPE consisting of gloves, gown, and mask as well. They must also practice strict medical asepsis, wash their hands before and after entering the patient’s room, wash or gel hands before and after providing care or upon removing gloves. Handling any respiratory devices must be done with sterile aseptic care. GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ • 11. Based on the clinical presentations, what nursing diagnoses should be high priority diagnoses for Mr. A? What are the appropriate nursing goals? What are the possible nursing interventions to achieve these goals? The nursing diagnosis that should be highest priority are: • ineffective breathing patterns related to inflammation and pain • impaired gas exchange related to fluid and exudate accumulation at the capillary-alveolar membrane • acute pain related to inflammation and ineffective pain management and/or comfort meausres. Appropriate nursing goals would be: • Clear breath sounds • Normal breathing patterns • No signs of hypoxia • Normal chest x-ray • No complications related to pneumonia Nursing interventions to reach these goals would be to begin antibiotic drug therapy, as well as providing fluids to help keep the patient hydrated and help loosen up secretions. Fluids would be monitored closely if the patient has heart failure. If the patient cannot swallow, then IV fluid and antibiotics may have to be administered. Patient must be placed in upright positions to prevent any aspiration, and must be moved every 2 hours from side to side to prevent any pooling of secretions and help facilitate lung expansion. Patient must try to eat in order to maintain nutrition and weight. Immediate collection of specimens and beginning the administration of antibiotics are critical. Oxygen therapy and breathing exercises can also be used. Nursing Science: Pharmacological Considerations • 12. The MD decides to admit Mr. A into the med/surg unit. What antibiotics do you anticipate the physician may order? What are the route? Antibiotic therapy for community-acquired pneumonia in an inpatient medical unit would be Respiratory fluoroquinolone OR β-Lactam plus macrolide, and the route would be IV until the patient is able to switch to oral therapy, once the patient is hemodynamically stable and able to swallow pills with a normally functioning GI tract. • 13. How to calculate the IV flow rate? Levofloxacin (Levaquin) 750mg IVPB is ordered. The dose is available in 250ml of 5% dextrose and to be infused over 90 minutes. How would you run the IV pump? This IV wound be runned as a piggy back or secondary IV line. • INJECTION (5 mg/mL in 5% Dextrose) Premix in Single-Use Flexible GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ • Desired Dosage Strength 750mg • From Appropriate Vial, Withdraw Volume 30 mL (30 mL Vial) Volume of Diluent 120 mL • Infusion Time 90 min • 14. If no IV pump is available and the IV infusion tubing administration set has a drop factor of 15 drops per ML. How many drops per minute would you regulate the above IV infusion? • 41.7 drops • 15. What is the relevant patient education information about pneumococcal vaccines (think from eligibility, route, expiration years etc)? Right Dose, Right Medication, right patient, right route, right time, right documentation, Right to refuse. Check medication expiration date, verify patients’ allergies or medication Contraindications. Patient should report to medical staff any dizziness, vision changes or ringing in the Ears, high fever or unusual behavior. GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ • Able to suction tracheostomy with supervision 3. This patient's ABG results are: pH 7.31; PaO2 68mmHg; PaCO2 58mmHg; HCO3- 32mEq/L; SaO2 85%. You would interpret that these findings indicate what respiratory status? Respiratory acidosis Patient has CO2 trapping hypo ventilating (keep CO2 inside) Asthma hyperventilating (exhale lots CO2) repiratory alkalosis brown back 3. Based on the results of ABG, what high priority nursing interventions should be implemented? Encourage patient to pursed lip breathing and deep breathing with effective coughing which will help clear secretions to increase oxygen delivery to the lungs, and pursed-lip breathing will prevent bronchiolar collapse and air trapping, reducing carbon dioxide retention. The oxygen rate should not be increased because in patients with chronic hypercapnia, the stimulus for breathing becomes low oxygen levels, and higher oxygen administration may cause respiratory arrest. Give patient Oxygen (goal 88-92 O2 sat) Negative pressure helps CO2 to be eliminated. 3. When you review the results of other lab tests (esp. CBC and BMP) and CXR, what you would expect to find as a result of M.B's exacerbation of COPD? (Hint: think from XCR, HCO3-, RBC counts etc) *Elevated Hct above normal range which is 37-48 % due to low availability of oxygen and possibly enlargement of right side of heart. *hypercapnia *RBC elevated An increased number of red blood cells (erythrocytosis). This occurs when the person has had low oxygen levels in the blood (hypoxemia) for a long period of time. Red blood cells carry oxygen in the blood. Because of damage to the lungs, a person with COPD often cannot get enough air. The body reacts by producing more red blood cells to try to increase the amount of oxygen in the blood. PaCo2 will go up. *hypoxemia (PaO2<60mmHg, SaO2<88%) and then hypercapnia (PaCO2>45mmhg) later in disease. GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ *Polycythemia develops as a compensation for hypoxemia (HgB>20g/dl) *chest x-ray might reveal barrel chest, hyperinflation, cardiac enlargement and flat diaphragm. 6. What kinds of diet will be appropriate for M.B to meet his nutritional needs? The diet that is recommended is a high-calorie, high-protein diet. Around 3L/day recommended of fluids. It is recommended to eat 5-6 small meals daily to avoid bloating and satiety. Nursing Science : Pharmacological Considerations 7. How should you teach M.B about using MDI? (Hint: open mouth, hold breath, shake, rinse mouth, spacer, how to know it is empty etc) Step 1: take off cap and shake inhaler Step 2: Breathe out all the way Step 3: hold inhaler the way your doctor says. (Pics below) Step 4: Start breathing in slowly through your mouth, and press down 1 time on inhaler. Keep breathing in slowly as deep as possible Step 5: Hold your breath as you count to 10 slowly (if you can). Step 6: For inhaled quick relief medicine (B-agonists) wait 1 minute between puffs. Usually 2 puffs recommended. Step 7: rinse mouth after done to prevent candida Clean inhaler: look at hole and see if there is powder around the hole. If so clean inhaler. Remove the metal canister. Rinse only the mouthpiece and cap in warm water. Let them dry overnight. Know when empty: For medications that are used every day, calculate the number of days the inhaler should last by dividing the number of puffs in the canister by the number of puffs taken daily. For quick release or prn medication, count each puff. Never put canister in water to see GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ if it is empty. 8. You formulate a nursing diagnosis of imbalanced nutrition: less than body requirements for this patient. What appropriate nursing interventions should you implement? Assess dietary habits, recent food intake. Note degree of difficulty with eating. Evaluate weight and body size. Patient in acute respiratory distress is often anorectic because of dyspnea, sputum production, and medications. In addition, many COPD patients habitually eat poorly, even though respiratory insufficiency creates a hypermetabolic state with increased caloric needs. Encourage a rest period of 1 hr before and after meals. Provide frequent small feedings. Avoid gas-producing foods and carbonated beverages. Avoid very hot or very cold foods Administer supplemental oxygen during meals as indicated. Table 5-48 COPD Drugs LABA (take regularly) serevent SABA (rescue) albuterol (CNS activation, palpitations), xopinex, Cortcosteroid cortisone, prednisone, Medrol GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ 5. What signs/symptoms from C.J may indicate he is improving? O2 sat, louder wheezing 6. C.J has a minimal-moderate response to the initial treatments, and the MD orders IV methylprednisolone (Solu-Medrol) to be given. What should you explain this drug to the patient? (Think from indication, side effects, patient education etc) Helps with inflammation in airway, decrease suptum 7. As you provide timely care to this patient, what nursing activities could be most appropriately delegate to nursing assistive personnel (NAP)? Vitals, set up oxygen, need to take over if explain anything 8. C.J. is to received albuterol nebulizer treatment Q2h and PRN, Methypredisolone 60mg IVP Q6h and O2 tx NC at 4LPM. ABG is drawn and results show pH 7.36; PaO2 70mmHg; PaCO2 44mmHg; HCO3- 24mEq/L; SaO2 92%. Based on the information, what will be your best nursing action? Need to closely monitor because patient’s body is compensating 9. Nursing Science : Pharmacological Considerations 10.9. What are the difference between long and short acting β- adrenergic agonists? Nursing considerations? Patient education? Listed above, , 10.Name of few example medications of long and short acting β- adrenergic agonists. Listed above 11.Nursing Science : Health Promotion and Maintenance GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ 12.11. What should nurses be monitoring for when administering Albuterol (Proventil) to relieve severe asthma? What are the rationale? Listed above, monitor headache, palpitations 13.What C.J received Adrenergic beta agonist for asthma, he complains of palpitation, chest pain and throbbing headache. What is the most appropriate nursing action? What should patients be screened for before start taking such medication? Rationale? Stop med, anxiety, cardiac, increased risk of side effects Pleural Effusion Pleural Effusion: Case Study: History GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ o Mr. C is a 25-year-old man presents with a 5-day history of right-sided chest pain and describes it as a ‘catch in the breath’. It gets worse with deep breathing and coughing. During this period, he has developed a fever, which is more pronounced in the evening. He also complains of a dry cough. Over the past 2 days, he has developed breathlessness, which has worsened rapidly. He is an otherwise healthy bank clerk who has not suffered from any other illness. He does not smoke or drink alcohol and is not taking any medication. Mr. C's Physical Exam Findings o Physical examination reveals mild pallor. His pulse is regular at 110 beats/min and his blood pressure is 120/82 mmHg. Respiratory rate is 26/min. o The trachea is shifted to the left side and the apical impulse is shifted laterally. o The right side of the chest moves less with respiration. o Tactile vocal fremitus is reduced. o On percussion, a stony dull note is elicited on the right side and this dullness does not shift with change in posture. o Breath sounds and vocal resonance are almost absent on the right side. There is no succussion splash. o Abdominal, cardiovascular and neurological examinations are normal. The rest of the physical examination is unremarkable. Nursing Science : Physiological Integrity • 1. What clinical presentations will support Mr.C's diagnosis of pleural effusion? Hint: Pleuritic pain that is sharp and increases with inspiration + progressive dyspnea with + dry, nonproductive cough. Main Symptoms: Dyspnea (SOB), Dry, nonproductive cough Occasional sharp, non-radiating chest pain that is worse upon inhalation (inspiration) Sputum production, Fluid ascites in space between the lungs and ribs Other associated signs can include: Possible pyrexia (raised body temperature → developing into high- GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ Pulmonary Embolism Lower Respiratory Case Study- Pulmonary Embolism 1. What can you identify from the patient's history that put her at high risk for the present illness? Oral contraceptives pose a great risk for PE. Smoking additionally puts a person at high risk for PE. Finally, as a computer programmer, I suspect she spends much of her day sitting. Although this patient was otherwise healthy, these risk factors may explain her illness. 2. Based on the clinical presentation, pulmonary embolism is suspected as a result of DVT. What is the non-invasive diagnostic study that can identify DVT? Venous doppler can be used to diagnose DVTs. This test is essentially an ultrasound that is used along the major veins of the extremities (mainly lower extremities). A doppler can diagnose superficial or deep venous thrombosis. 3. What types of patient population have the highest risks for developing a PE? GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ The patients with the highest risk of pulmonary embolism are patients who have post op, cancer, bariatric,left sided heart failure, patients who are immobile, patients who had surgery within the last 3 months, patients with a history of DVT, obese patients, childbirth, cancer patients, and patients who have a clotting disorder. 4. A patient has a total hip replacement. What clinical presentations from the patient indicate that the plan to prevent postoperative thrombus formation has been ineffective? Clinical presentations would be SOB, dyspnea, cyanosis, tachycardia, sudden chest pain, hemoptysis, hypoxemia, and tachypnea. Additionally, DVT symptoms might include unilateral calf pain or swelling. 5. What blood work would you be expected to find in Mr.D's case? (Hint: D- dimer, aPTT, PT/INR?) What's the clinical significance of D-dimer? D-dimer is a lab test that measures the amount of crosslinked fibrin fragments. These fragments are the result of clot degradation. Disadvantage is that it is neither sensitive or specific. If D- Dimer is elevated, may be a clot. If it is normal, rule out DVT. Monitoring lab results to insure therapeutic ranges of INR if pt is taking Warfarin. aPTT for IV heparin. Anticoagulant therapy should continue for at least 3 months. INR levels are drawn at intervals and Warfarin dosage is adjusted. 6. The MD orders heparin IV drip and Coumadin (Warfarin) after the sign of PE and DVT have subsided. What are the mechanism differences between heparin and Coumadin treatment in Mr.D's case? What are the antidote to each medication? What lab values should you monitor for each medication? Heparin is an anticoagulant that prevents the formation of blood clots by binding to antithrombin III to make it more actively bind to thrombin which then inhibits thrombin from forming clots. This mechanism differs from the mechanism of Coumadin which involves the interference of the vitamin K cycle, which is involved in the coagulation factors needed to form clots. The antidote to heparin is protamine sulfate while the antidote to Coumadin is vitamin K. The lab values we would monitor for heparin are activated partial thromboplastin time (aPTT), and for coumadin, the international normalized ratio (INR) which both measure how long it takes for the blood to clot. Monitor aPTT and INR for therapeutic dose not prophylaxis. GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ Hypertension Case Study Questions 1-7 ● J. G. is a 50-year-old African American man who comes monthly to the community health screening for blood pressure checkups. He says he had some headaches lately and a little dizziness. ● Initial Objective Data ● Alert and oriented and cooperative ● 5 feet 10 inches, 240 pounds ● Blood pressure 172/94, pulse 90, respirations 24, temperature 97.0° F ● Subjective Data ○ Is a truck driver and eats a lot of fast foods ○ It is hard to eat healthy on the road ○ Smokes one-half pack of cigarettes per day for 30 years ○ Drinks at least a 6-pack of beer a day when he is not working ○ States that he feels fine and is not a “hyper” person ○ Has heard that BP drugs “make you impotent” 1.What misconceptions about hypertension should be corrected? a) “Hyper” and hypertension are the same diagnosis. Being hyper and having hypertension are two completely, unrelated topics. GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ ○ Blood pressure: 166/108 mm Hg ○ Sustained apical impulse palpable in the fifth intercostal space just lateral to the midclavicular line. ● Diagnostic Studies ○ ECG: left ventricular hypertrophy ○ Urinalysis: protein 30 mg/dL (0.3 g/L) ○ Serum creatinine level: 1.6 mg/dL (141 mmol/L) ● Collaborative Care ○ Low-sodium diet ○ Hydrochlorothiazide 25 mg/day 3.What risk factors for hypertension does R.L. have? -Age: at 50 years of age, SBP rises dramatically - He eats a lot of fast foods/thinks it is hard to eat healthy food: excessive sodium and elevated serum lipid levels (hyperlipidemia/ high levels of cholesterol and triglycerides) - Smoker - Drinks at least a 6-pack of beer a day when he is not working - Gender: hypertension is more prevalent among men - Ethnicity: prevalence of hypertension is 2x higher in African Americans than in whites GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ - Obesity: at 5 feet 10 inches and 240 pounds, his BMI is 34.4 ( &gt; 29.9 indicates obesity) - Truck driver/sedentary lifestyle 4.What is the correct formula for blood pressure? What&#39;s the formula for cardiac output? - Blood Pressure = Cardiac Output x Systemic Vascular Resistance (BP=CO x SVR) - Cardiac output = stroke volume x Heart Rate (CO=SV x HR) 5.Blood pressure is regulated by what body systems? Think from pathophysiology. The nervous system reacts within seconds once the BP has dropped, and increases the BP by activating the sympathetic nervous system, which increases HR and promotes vasoconstriction, as well as the release of renin from the kidneys. BP can be reduced by reducing SNS activity or by activating the parasympathetic nervous system, which lowers the HR, thus reducing cardiac output. These activities are transmitted to the vasomotor centers in the brain stem by the barorecepters located in the carotid arteries and the aortic arch. The kidneys also use a hormonal mechanism to regulate BP by controlling sodium excretion and extracellular fluid volume. Sodium retention results in water retention, increasing ECF volume, and thus increasing venous return and stroke volume, and therefore increasing CO and BP. The kidney’s juxtaglomerular apparatus secretes renin (renin-angiotensin-aldosterone system) in response to SNS stimulation, decreased kidney blood flow, or decreased serum sodium concentration. Prostaglandins secreted by the renal medulla have a vasodilator effect, decreasing SVR and thus BP. The endocrine system is also involved in BP regulation because SNS stimulation results in the release of epinephrine along with a bit of norepinephrine by the adrenal medulla. Epinephrine increases the HR and thus the CO, as well as causing vasodilation. Increase blood sodium levels stimulates the posterior pituitary gland to release ADH, which increases ECF volume and thus CO and BP. 6.Which mechanism for blood pressure regulation has the fastest action? The sympathetic nervous system control of arterial pressure is the fastest mechanism for blood pressure control through the sensing of baroreceptors, which send the sensory information to the vasomotor centers in the brainstem. Within the renal system, angiotensin II (A-II) is a potent vasoconstrictor and increases SVR, and thus immediately increases BP as well, thought not as fast as the nervous system. GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ 7.What classification of hypertension does J. G. have? J.G has Secondary Hypertension exact cause is related to his Left Ventricular Hypertrophy, which is due to his sutsained high BP, causing an increase in his cardiac overload. The increased contractility increases myocardial work and O2 demand. 8.The most important long-term goal for a client with hypertension would be to? Lower BP, no longer require meds, prevent heart disease (CHF) or further complications of organ damage (kidney, eye, heart, blood vessels, brain). Need education, compliance, lifestyle change, annual screening. 9. How to obtain the diagnosis of hypertension? Take BP and 2 or more times the BP is elevated. If white coat moniter BP at home 10.What assessment findings can possibly indicate of target organ damage? Kidney (creatinine high), heart enlarged (apical pulse at clavicular line and EKG), Eyes 11. What possible side effects or adverse reactions are important for nurses to consider when initiating treatment of hypertension using ACE-inhibitors or ARB’s? Hypotension (both), orthostatic hypotension, (BOTH)dry mouth/cough (ACE), angioedema (ARB), hyperkalemia (ACE), Ace inhibitor less effective in African americans 12.When teaching a client about propranolol hydrochloride, the nurse should base the information on the knowledge of propranolol which may include: need to be careful with patient with asthma or COPD, hold beta-blocker if HR is low, check potassium for diuretic (3.5-5 normal), Ace inhibitor (check kidney function serum creatinine BUN, potassium) GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ C-reactive Protein- tests for inflammation inside blood vessels Cholesterol panel (total, HDL, LDL, triglycerides)- hypercholesterolemia is an additional risk factor Glucose, Hemoglobin A1c- tests for diabetes, additional risk factor Troponin I- rule out Heart attack, tests for cardiac muscle damage, every 8 hours x3 Myoglobin-cardiac ● Mr. Cameron indicated that his pain is in the middle of his chest and radiates to his left arm. It is about 6/10. He added that this was not the first time he had this pain. He said that the pain usually starts few minutes after gardening or climbing stairs and is relieved by rest. Angina is suspected. ● 5. What type of angina did Mr. Cameron just described? Chronic stable angina, which refers to chest pain that occurs intermittently over a long period of time with a similar pattern of onset, duration, and intensity of symptoms. It is often provoked by physical exertion (e.g. gardening or climbing stairs), stress, or emotional upset. Although most angina pain occurs substernally, it may radiate to other locations, including the law, neck, shoulders, and/or arms. The pain of chronic angina usually lasts only a few minutes and commonly subsides when the precipitating factors are resolved (e.g. resting). ● 6. Based on the pathophysiology of Mr. Cameron&#39;s conditions, his coronary artery had been blocked by at least ? (hint: a percentage number) Since Cameron has a history of CAD his ischemia was most likely secondary to atherosclerotic plaque in which the artery is usually blocked (stenosed) 70% or more (50% or more for the left main coronary artery). ● 7. Which diagnostic test can be utilized to confirm or visualize the occlusion/obstruction of the coronary arteries? ECG, chest xray, exercise stress test, coronary computed tomography, echocardiogram, electron beam CT scan, ECHO. Angiogram GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ ● 8. What&#39;s the pathophysiology cause of Mr.Cameron&#39;s chest pain? (hint: think from O2 demand and supply) The pain is caused by increased demand for O2 or a decrease supply of o2. Could be caused by narrowing of one or more coronary arteries by atherosclerosis, so in this case could be due to the lack of O. Chest Pain Mr. Cameron is a 66-year old Caucasian gentleman who has a history of CAD. This morning while he was gardening, he felt “some chest pain.” He drove himself to the ED. Mr. Cameron indicated that his pain is in the middle of his chest and radiates to his left arm. It is about 6/10. He added that this was not the first time he had this pain. He said that the pain usually starts few minutes after gardening or climbing stairs and is relieved by rest. Angina is suspected. You connect Mr. Cameron to ECG and observe the following rhythm: GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ 9. How do you interpret the above rhythm? • T wave is inverted , indicating myocardial ischemia. (yellow) T wave shows ventricles “repolarizing”/ relaxing, so an inverted T wave is showing them depolarizing. • P wave present (pink). P wave shows atrial contraction, originating in the SA node. o P wave is on the smaller side • QRS present, ventricles are contracting. (green) • PR interval is 4-5 boxes, good finding. Note no widened PR interval. (light pink) 10. T-wave inversion on EKG indicate ? • The inverted T wave can mean anything from a normal life to sudden death. Some people are able to function with this heart rhythm, while it causes others to die suddenly. Acute coronary ischemia, CNS injury, and a pulmonary embolism can all cause an inverted T wave. • In this situation, the T-wave inversion indicates acute coronary disease resulting from myocardial ischemia , or a myocardial infarction. 11. The ED MD examines this patient and based on the ECG findings diagnosed him angina. The MD orders MONA, what does MONA stand for? • MONA stands for morphine, oxygen, nitroglycerin, and aspirin. Its an acronym used to help medical professionals treat acute coronary syndrome. GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ How often does it get tested? Other clinical significance? • Troponin I is the most sensitive and specific for myocardial injury. • In the hospital these levels are checked 3 times over 24 hours, so every 8 hours. The values will continue to go up in the amount of time. • Troponins are a class of regulatory proteins that control muscle contraction. Testing troponin levels helps in the diagnosis and prognosis of AMI. • Troponin Values: o Troponin I < 0.4 ng/mL o Troponin T < 0.2 ng/mL 18. Why another 12-lead ECG is ordered here? • A repeat ECG may be necessary to assess the effectiveness of drug therapy at one point in time. Deviations from the normal sinus rhythm can also indicate heart problems. 19. When you reassess Mr. Cameron. He says the pain is now 4/10 but not complete relieved, BP 90/50, HR 110, SaO2 92%, RR 22. Why patient's BP dropped? • Nitroglycerin, which is a medication given for angina, helps to relieve chest pain but it is also a vasodilator so low blood pressure is a side effect. 20. Mr. Cameron tells you that he is not sure that the NTG is still good. How can you tell if NTG has expired or still active? Where should NTG be stored? GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ • Active NTG should have a slight burning sensation if placed under the tongue. It should also be replaced every 6 months. Nitroglycerin should be in a dark, air-tight container (brown bottle) because it is photosensitive to light and air. • 21. How would you teach the patient to prepare for the stress test? MIBI stress test? (hint: diet, medication, skin prep etc) Patients must wear comfortable clothes and shoes used for walking. Beta blockers held 24 hours before test to accurately be able to measure the HR and achieve the maximal hr . No caffeine containing food or fluids w/in 25 hours. No smoking / strenuous exercise 3 hours before test. • 22. How would you explain the stress test to Mr. Cameron? When to terminate the test based on the patient's complains or vital signs? • The stress test will entail 3 min stages set up for 3 speeds and elevation on treadmill. • Patient able to walk on a flat surface for 6 min. Pt. can exercise to either the predicted peak HR ( 220 - person’s age) or peak exercise tolerance (once reached, test will end). If any chest discomfort, significant changes in vital signs from baseline, or significant ECG changes- test will be stopped. • 23. If Mr. Cameron can't tolerate a physical stress test, what are his options? Ambulatory ECG Monitoring - Holter monitoring which records ECG rhythm 34-48 hrs and correlates rhythm changes with symptoms and activities recorded in diary. Event monitor or loop monitor: records rhythm disturbances not frequent enough to be recorded in one 24 hr period. Allows for more freedom than Holter monitor. Some record in real time and sent directly to receiving unit. -If unable to walk or run, can give medication IV: persantine or adenocard and cause stress on heart • 24. What information should you include when developing a healthy life style teaching plan for Mr. Cameron? (hint: modifiable risk factors, diet, exercise etc) No smoking, reduce weight, increase exercise, dietary changes include: restrict salt, sodium, cholesterol, and saturated fats. • Six months later, Mr. Cameron comes back with severe chest pain. Per Mr. Cameron, this time the pain started while he was sleeping. He took 3 pills of NTG, but it didn't help, so he called 911 and was brought to ED. You connect him to ECG monitor and observe the following: GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ • • 25. How do you interpret this rhythm? Type 2 heart block ‘Wenckebach’ with ST elevation ( → STEMI) • 26. ST elevation indicates Acute Myocardial infarction ? • 27. Serum troponin is ordered. The result is 0.4ng/dL, what is the normal range for troponin? How to interpret this value? Is one test/value of troponin enough to confirm or rule out the diagnosis? Per Medical Surgical Nursing textbook, normal ranges for troponin are <0.5 ng/mL, suspicion for myocardial injury values range 0.5- 2.3 ng/mL. This value of 0.4ng/dL (0.004ng/mL) would be not be indicative of a myocardial infarction, but close to suspicion of one. A troponin test cannot fully rule out a MI, 12 lead electrocardiogram and CT angiogram (w/ contrast) can help to rule out if MI (STEMI or NSTEMI) is present. Need multiple tropinion test (3) It's been 30 minutes and the chest pain hasn't been relieved completely even with Nitroglycerin IV drip. Troponin is elevating. Therefore, acute MI is the diagnosis now. Bnp lvls go up when the heart is crappy • 28. What is the major pathology of AMI? What is the goal of treatment? GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ Admitting Data: • Name: M. H. • Age: 60-year-old. • Gender: Female. • Medical History: o HTN x 15 years. o MI in 2012. o Atrial fibrillation in 2012. o Hyperlipidemia x 7 years. • Surgical History: o Appendectomy in 2000. • Allergies: o PNC (skin rash). o Lisinopril (angioedema). • Psychosocial History: o Marital status : married. o Education level : some college. o Social resources : none. o Spiritual resources : attending Church on holidays. o Occupation : administrative assistant. GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ o Employment : retired due to disability . o Smoking : smoked for 5 years; quit in 2012. o Alcohol : social drinker (only on holidays, soft liquor). o Recreation drugs : during high school only. GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ 1.Substernal pain is highly associated with cardiovascular events. True OR False? true 2.Notice how many pillows the patient is using and what that may indicate? Paroxysmal nocturnal dyssnpea ??? 2. From this patient's history, what are the modifiable and non-modifiable cardiovascular risk factors? Age, gender, ethnicity, family hx, smoking, alcohol use, 4.Knowing that Mrs. M.H developed HF after MI. Her MI was most likely Q-wave MI or non Q- wave MI? Q-wave MI deeper and longer Q wave, deprived of circulation for more than 2 hours MI cell going into necrosis 5.Since the patient is allergic to Penicillin, she should not receive Amoxil (Amoxicillin) Vancomycin GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ ▪ fatigue, ▪ episodes of paroxysmal nocturnal dyspnea and orthopnea x 3 weeks. o Objective Data: ▪ Tachypnea and tachycardia, ▪ diaphoresis, ▪ JVD at Fowler's position, ▪ ▪ laterally displaced point of maximal impulse, ▪ S3, ▪ s4, ▪ systolic murmur of mitral regurgitation; ▪ hepatojugular reflux (HJR), GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ : enlarged cardiac GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ ▪ 2 + pitting edema to mid shin bilaterally. ▪ • Diagnostic findings at admission: o Brian natriuretic peptide (BNP): 1,100 pg/mL. Helps diagnose CHF o o consolidation. o Echocardiogram : a LVEF of 32%, with dilatation, no wall motion abnormalities. LVEF- 55-70%, systolic murmur LVEF decreased, diastolic murmur LVEF normal ▪ o Serial EKGs : atrial fibrillation. ▪ Medical Diagnosis: Acute decompensated heart failure (ADHF). S1- beginning systole closure AV valve, lub S2- end systole, semilunar valve, dub Murmur btw S1 and S2 systolic murmur, abnormal heart valve S3 S4 S1 S2 S3 S4 diastol e systol e diastol e Edema- diuretic, monitor fluids, low sodium, elevate legs GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ Serial troponins: negative. Rule out MI Chest x-ray mild pulmonary edema without effusion, and GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ 10.Classify the clinical manifestations of right-sided vs. left-sides HF. R side HF- edema, ascites, JVD, hepatomegaly, back into up to R ventricle to R atrium and not returning L-side HF- pulmonary congestion, edema, SOB, orthopnea, heart not pumping enough blood out so the blood backs up in lungs 11. Mrs. M.H. has systolic or diastolic HF? Systolic, ejection fraction 32% below normal range 50-70% 12.BNP is a major marker of CHF and is released in response to Pressure in heart stretching ventricles 13.Explain to Mrs. M.H why she experiences paroxysmal nocturnal dyspnea Laying flat means heart works harder to pump to extremities 14.How to auscultate the mitral murmur (bell or diaphragm)? Where? All physicians take money: 5th intercostal space left midclavicular line 15.The presence of JVD indicates • central venous pressure (CVP). Head-to-toe assessment on the day of care: o General Status: Patient alert and oriented, somewhat seems anxious and dyspneic. GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ Coagulation: Test Normal Range Patient's Result PT T 25 - 35 seconds 37 seconds PT 25 - 35 seconds 44 seconds INR 1.0 2.0 INR elevated on purpose due to taking coumodin, 2 is therapeutic dose Coagulation: Test Normal Range Patient's Result BNP <100 pg/L 200 pg/L Troponi n <0.1 ng/mL <0.1 ng/mL Lipid Panel: Test Normal Range Patient's Result Cholesterol < 200 mg/dL 256 mg/dL HDL Male: > 40 mg/dL Female: > 50 mg/dL 40 mg/dL LDL 140 - 280 mg/dL 280 mg/dL Triglycerid es <150 mg/dL 210 mg/dL 16.Discuss the pathophysiology of abnormal lab values and physical assessments. • Discuss above Medications: GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ Drug Dose Route Classification Specific Indica Lasix (Furosemide) 40 mg x once IV Loop diuretic Edema Lasix (Furosemide) 20 mg BID PO Loop diuretic Edema Hydrochlorothiazide 25 mg daily PO Diuretic thiazide HTN Capoten (Captoril) 12.5 mg daily PO ACE-inhibitor HF/remodelin Warfarin (Coumadin) 2 mg daily PO Anticoagulant Thromobosis Digoxin (Lanoxin) 0.125 mg Q 8 hours IV push over 3 min Inotropic agent Impaired cont Potassium 2 tabs daily PO Supplement Hypokalemia Zocor (Simvastatin) 2 mg HS PO Antilipids Hyperlipidemi Morphine 2 mg PRN Q 6 hours for pain IV push over 3 min Opiod analgesic Chest pain GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ • CHF after IMI- Ace inhibitor drug of choice • Digoxin- hypokalemia- may experience toxicity, too much hyperkalemia- normal dose digoxin not effective ( need stronger dose) Analysis and Synthesis: Mrs. M. H. is a patient who has cardiovascular risk factors (i.e. HTN, smoking, MI) that lead to heart failure. Based on her symptoms, the patient is having stage III (or stage C) heart failure. She is hospitalized for acute decompensated heart failure as evidenced by her significant cardiovascular (edema, JVD) and pulmonary (dyspena, crakcles, desaturation) symptoms as well as diagnostic tests (high BNP, cardiomegaly and infiltration on CXR). Based on the findings from the history, physical exam, and diagnostic studies, the patient's prioritized needs are: 1. Physiological Needs (High Priority) ▪ Oxygenation : as evidenced by dyspean, orthopnea, desaturation, and crackles. ▪ Circulation: as evidenced by edema, JVD, extra heart sounds, cardiomegaly, fatigue, low EF, murmur, high BNP. 2. Physiological Needs (low Priority) ▪ Fatigue : as evidenced by activity intolerance. GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ ▪ Skin Integrity : as evidenced by edema. 3. Basic Care and Comfort ▪ Mobility: ▪ Skin care ▪ anti-embolic ▪ positioning ▪ Elimination: ▪ Strick intake and output ▪ Nutrition: ▪ Adjust diet ▪ Rest and Sleep 4. Pharmacological and Parenteral Therapies ▪ Adverse effect of medications: ▪ Allergic reaction to medications: ▪ Dosage calculation: ▪ Physiologic response (i.e.VS, lab): 5. Health Promotion and Maintenance ▪ Immunization: ▪ Slowing disease progression: ▪ Risk factors modification: ▪ Sexuality: ▪ Self-Care: 6. Safety and Infection Control: ▪ Allergies: 7. Psychosocial Needs: ▪ Anxiety: ▪ Nonadherence: EKG Chest Pain Please interpret the following strip and regularity, calculate heart rate and explain relevant nursing care accordingly. 1. This looks like normal sinus rhythm-no nursing intervention necessary. Regularity:R-R intervals are constant Rate:The atrial and ventricular rates are equal P wave:P waves are uniform. There is one P wave in front of every QRS complex. PRI: PR interval is 0.12 sec GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ cardiovascular life support (ACLS) with the use of a defibrillator and definitive drug therapy ( epinephrine, vasopressin) 10. ● This strip is displaying ventricular tachycardia ● Wide QRS at 0.12 seconds ● Abnormal HR is a characteristic of Ventricular tachycardia (100-250 bpm) ○ HR calculated from this ECG: 150 bpm (Count the small boxes between 2 complexes. HR = 1500 divided by # of small boxes) ● P wave abnormal ● Regular rhythm ● Elevated Q ● Sustained VT causes a severe decrease in CO because of decreased ventricular diastolic filling times and loss of atrial contractions. This results in hypotension, pulmonary edema, decreased cerebral flow, and cardiopulmonary arrest. ● This dysrhythmia must be treated quickly. Episodes may recur if prophylactic treatment is not given (VF may also develop) GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ ● Treat the precipitating causes ● Discontinue drugs that can prolong the QT interval ● Drug therapy. Cardioversion used if drug therapy is ineffective ● VT without a pulse is life threatening 11. ● P wave upright, one P wave for every QRS complex, no Afib or flutter waves present ● Regular atrial rhythm -- atrial rate is 75 bpm ● PR interval is normal duration ● No q wave visible, Ventricular rhythm irregular -- ventricular rate is 75 bpm ● QRS complex is .10 seconds -- normal duration ● ST segment is not flat, is elevated ● T wave is upright, QT is prolonged -- 0.6 seconds ● HR is 75 bpm ● Irregular ventricular rhythm, ST segment elevation indicates pericarditis, leading to possible MI ● Treatment: reduce pain and inflammation with aspirin or NSAIDs, and treat underlying cause whether it is infection or not and determine if other more direct treatment is required Mr. Cameron is a 66-year old Caucasian gentleman who has a history of CAD. This morning while he was gardening, he felt “some chest pain.” He drove himself to the ED. Mr. Cameron indicated that his pain is in the middle of his chest and radiates to his left arm. It is about 6/10. He added that this was not the first time he had this pain. He said that the pain usually starts few minutes after gardening or climbing stairs and is relieved by rest. Angina is suspected. You connect Mr. Cameron to ECG and observe the following rhythm: GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ 9. How do you interpret the above rhythm? • T wave is inverted , indicating myocardial ischemia. (yellow) T wave shows ventricles “repolarizing”/ relaxing, so an inverted T wave is showing them depolarizing. • P wave present (pink). P wave shows atrial contraction, originating in the SA node. o P wave is on the smaller side • QRS present, ventricles are contracting. (green) • PR interval is 4-5 boxes, good finding. Note no widened PR interval. (light pink) 10. T-wave inversion on EKG indicate ? GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ • Troponin I is the most sensitive and specific for myocardial injury. • In the hospital these levels are checked 3 times over 24 hours, so every 8 hours. The values will continue to go up in the amount of time. • Troponins are a class of regulatory proteins that control muscle contraction. Testing troponin levels helps in the diagnosis and prognosis of AMI. • Troponin Values: o Troponin I < 0.4 ng/mL o Troponin T < 0.2 ng/mL 18. Why another 12-lead ECG is ordered here? • A repeat ECG may be necessary to assess the effectiveness of drug therapy at one point in time. Deviations from the normal sinus rhythm can also indicate heart problems. 19. When you reassess Mr. Cameron. He says the pain is now 4/10 but not complete relieved, BP 90/50, HR 110, SaO2 92%, RR 22. Why patient's BP dropped? • Nitroglycerin, which is a medication given for angina, helps to relieve chest pain but it is also a vasodilator so low blood pressure is a side effect. 20. Mr. Cameron tells you that he is not sure that the NTG is still good. How can you tell if NTG has expired or still active? Where should NTG be stored? • Active NTG should have a slight burning sensation if placed under the tongue. It should also be replaced every 6 months. Nitroglycerin should be in a dark, air-tight container (brown bottle) because it is photosensitive to light and air. Endocarditis Mr. Kobe Bryant is a 35 y/o African-American male who was admitted with fever and hypotension. A CBC was drawn and showed WBC = 13,000/mm3. His Echo showed "aortic valve vegetation" and "low ejection fraction". Vegetation- Plaque growing on valve, can visualize from echo, could break off and cause PE Ejection fraction: normal 50-70 The admitting physician updates the admitting diagnosis as "Infective Endocarditis". Once you know Mr. Bryant's diagnosis, you look to see if the Emergency Department RN did which of the following? Blood cultures * most relevant, positive staph or strep, negative- cant simply rule out IE due to slow growing, keep specimen growing x2 weeks, clean area, draw 2 different sides, 30 mins apart Sputum cultures * clean GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ area Urinalysis* Occult Blood test * True or False. It is possible for someone with IE to come back with negative blood cultures. True* False Which one of the following reveals a risk factor / etiology for Mr. Bryant's condition? 2 congenital birth marks on backside A single episode of diarrhea about one month ago Family history of maternal and fraternal grandfathers with HTN Medical history of strep throat about 4 months ago* bacteria could move to heart GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ Fluid volume excess related to decrease contractility manifested by hypotension GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ Cant stop antibiotics mid-way through b/c rheumatic heart disease, resistance to meds, and bacteria flow to kidneys Mr. Bryant is concerned about his diagnosis. He tells you, "I have no medical background - I play basketball. The doctor didn't explain this to me - Can you please tell me what is going on in my body?" Based on your understanding of the pathophysiology of infective endocarditis (IE), the following is an appropriate nursing diagnosis? Decreased Cardiac output related to valvular dysfunction manifested by low EF* Endocarditis related to pharyngitis manifested by hypotension and fever. Risk for infection related to group A beta- hemolytic streptococci infection https://youtu.be/vNuijvjGZBE On Day 2, you return for your second 12-hour shift. Which of the following findings indicates that the patient's endocarditis has worsened? Why? Ejection fraction measures 65% normal 50-70 Serum potassium 4.8mEq/L normal 3.5- 5 Absent of murmur good WBC increases to 18,000/mm3* Clinical manifestations of IE could include which of the following? Select ALL that apply. splinter hemorrhages* Osler's nodes* Janeway's Lesions* Hemorrhagic retinal lesions* GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ You know that treatment for infective endocarditis involves which of the following? Select ALL that apply. Accurate identification of infecting organism* Long-term antibiotic treatment* 2-3 months Bacterial use strong sensitive antibiotics, if fungal- valve replacement Short-term antibiotic treatment Corticosteroids Mr. Bryant has greatly improved and is ready to be discharged. The rounding physician puts discharge orders in for you. Which of the following must be included in the teaching plan of the patient? Select ALL that apply. Prophylactic antibiotic is required before any dental procedures. * Endocardiocentesis may be needed if the medical treatment fails. Brush thoroughly 2-3 times a day and floss daily.* Prescribed antibiotics must be completed at home via IV route.* rigorous long term antibiotics, so need long term IV Prophylactic Coumadin (Warfarin) will be needed for the rest of his life. * Pleuralcentesis-fluid out of lung Paracentesis- suck out GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ ascites abdomen Paracardiocentesis- fluid from heart Percarditis Mr. Daniel Craig is a 28 y/o Caucasian male who has been admitted with "Acute Pericarditis". He tells you he has "severe, sharp chest pain. It hurts so much that I can't take a deep breath or lie down". Medical Hx: HTN x 2 years, HLD x 2 years Surgical Hx: Tonsillectomy Family Hx: Father died at 47 from MI, Mother alive with HTN, CAD, HLD, Uncle died at 52 from MI Medications: None on record. What position can you put him in to make him more comfortable? High fowlers position GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ True or False: Most cases of acute pericarditis are idiopathic. True.* False. Chest Pain gets worse with breathing in and out b/c lung field has more pressure on pericardial sac Which of the following are classical symptoms of pericarditis? Select ALL that apply. auscultation of friction rub that correlates with patient's pulse.* auscultation of friction rub that correlates with patient's breathing. Prominent heart sounds. ST elevation in most leads in ECG.* Pleuritic pain that gets worse with inspiration.* Pain that worsens in supine position* Pericarditis & Chest Pain https:// www.youtube.com/embed/eCbF9G2qt80?wmode=opaque What is the hallmark sign of acute pericarditis? Pericardial friction rub GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ may be required to tip the syringe under the subxyphoid process toward the heart. To measure pericardial pressures, a stopcock on the needle is connected to a pressure line and transducer. 5. Advance the needle into the pericardial space. Passage of the needle through the skin may block the needle with subcutaneous tissue. Flush any tissue that may have accumulated during passage before entering the pericardium, a tough fibrous membrane. Use caution when advancing the needle through the diaphragm, as excessive forward pressure may result a sudden jump through the pericardium into a cardiac chamber. 6. Confirm intra-pericardial position with hemodynamics or echo contrast imaging. 7. Place the pericardial drainage catheter. The needle is exchanged over a guide wire for a multiple side- hole catheter. Pericardial and RA pressures are measured again, the effusion is aspirated, and pressures are measured once more after the pericardial space is empty . 8. Obtain serial echocardiograms before and after removal of the pericardial drainage catheter to confirm the absence of fluid re-accumulation. Remove the pericardial drain after 24-48 hours. Should fluid recur, consider a surgical pericardial window. You realize that anxiety and acute pain are two major nursing diagnoses relevant for your patient. What intervention would aid your patient with anxiety? Select ALL that apply. √ Simple, complete explanations of all procedures √ Simple, complete explanations of possible causes of pain * Alleviate pain with anti inflammatory medications as prescribed Position patient at 30 degrees Position patient at 45 degrees* GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ shiny taut appearance on skin of lower legs, ankles, and feet* True. False.* (PAD) GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ Provide an overbed table for support Leave the patient alone as often as possible See a real patient with Pericarditis https:// www.youtube.com/embed/Edtxhc4Rixk? wmode=opaque Peripheral artery disease What is the difference between Peripheral artery disease and peripheral venous disease? How do the wounds differ? Which is more superficial? PAD- arthrosclerosis plaque, cold feet and toes, no hair distribution, palor, dry, no enough nutrients, edema, dangle leg, numbness, lose sensation, prevent injuries, no bare foot, Diagnose: Pallor, pale, prosthesis, uselessness, pain, intermittent pain while walking (cortication) rest and walk in a little bit Test: Doppler, segmental BP- if drop from above the knee to below knee is less than 30 degrees It is PAD Systolic BP from brachial to radial should drop PAD or DVT- elevate leg, warm to touch, wet, hair growth, wet ulcer, edema, more superficial Skin temp, pulse, color to check patency under bypass is fine Your patient has chronic peripheral artery disease (PAD) of the legs and an ulcer on the left great toe. You would expect to find which of the following? Positive Homan's sign swollen dry scaly ankles a large amount of drainage from the ulcer prolonged capillary refill in all the toes * Intermittent claudication is peripheral venous problem. True or False. Mitral- stenosis, regurgitation MRS ASS Mitral regurgitation (systoic murmur) mitral stenosis (diastolic murmur) GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+ Aortic- S1 S2 S1 S2 AV valve Semilunar valves Systolic murmur (btw S1 and S2) Diastolic Murmur (after S1 and before S2) Normally: mitral valve opens blood goes to ventricle Mitral stenosis- not enough blood flowing through Mitral stenosis- Left atrium blood to Left ventricle not enough blood flows from LV so pressure in LA is higher Mitral regurgitation- no blood should flow back from LV-LA, but the blood does flow to LA so the pressure in LA increases Mitral Valve- apex 5th intercostal space midclavicular line Aortic- semilunar valves; stenosis- Aortic not able to open completely, not enough blood so it pools in LA All physicians take money Regurgittaion- L ventricular hypertophy GNRS 555-Case Study EXAM Upper Respiratory Diseases Questions With Answers Rated A+