NR 603-Week 3 quiz And NR 603 - Week 3 iHuman ( Joseph camella 66 years, Dyspnea)Latest Up, Exams of Nursing

Download NR 603-Week 3 quiz And NR 603 - Week 3 iHuman ( Joseph camella 66 years, Dyspnea)Latest Up and more Exams Nursing in PDF only on Docsity! NR 603-Week 3 quiz And NR 603 - Week 3 iHuman ( Joseph camella 66 years, Dyspnea)Latest Update 2024/2025 Combined A 60 year old male with a history of type 2 Diabetes and HTN comes in for a follow up blood pressure check to evaluate the recent medication/diet/exercise plan you prescribed at his visit 3 months ago. His BMI is 20 His Blood pressures sitting and standing are: 138/80 132/76 What is the best analysis of the prescribed treatment plan a. His blood pressure is within JNC 8 guidelines so no adjustments will be made at this time b. his blood pressure is within JNC 8 guidelines but there should be less variability with position change c. His blood pressure is within JNC 8 guidelines but there should be less variability with position change d. His blood pressure is NOT within JNC 8 guidelines and therefore his therapy needs to be increased - Correct answera. His blood pressure is within JNC 8 guidelines so no adjustments will be made at this time You are reviewing the labs of a 50 year old female patient who presented to you for a physical exam. You note, upon review of her labs, that her triglycerides are 670. Triglyceride levels over 500 raise immediate concern for which of the following disorders? a. liver failure b. acute pancreatitis c. myocardial infarction d. pulmonary embolism - Correct answerb. acute pancreatitis A 44 year old male patient presents to the clinic for evaluation of an episode of chest tightness that radiated to his back that he had earlier in the day when he was out for a walk. He states that once he came home and sat down, the chest tightness resolved. What is the most likely cause of his chest tightness? a. dissecting aortic aneurysm b. angina pectoris c. Gastroesophageal disease - Correct answerb. angina pectoris A 52 year old caucasian male with a past medical history of COPD comes in for follow up on his stage 2 HTN. Hydrochlorothiazide is at the maximum dose and a new medication needs to be added. Which medication would be the best second line therapy? a. a calcium channel blocker such as Cardizem b. an Ace inhibitor such as Lisinopril c. a beta blocker such as Metoprolol d. an alpha 1 receptor blocker such as cardura - Correct answera. a cab. an Ace inhibitor such as Lisinopril Which of the following drugs does the 8th Joint National Committee (JNC8) 2014 Evidence Based Guidelines for the Management of High Blood pressure in adults recommend for the treatment for Caucasian males with microalbuminuria? a. Diruetics b. Angiotensin-Converting enzymes (ACE inhibitors) c. calcium channel blockers d. beta blocker - Correct answerb. Angiotensin-Converting enzymes (ACE inhibitors) Exercise tolerance Test (ETT) is the first line approach to detecting CAD in stable patients. However ETT is contraindicated for some patients. Knowing when to consult with specialists is an important part of NP practice. Which patient should be referred to cardiology prior to ordering an exercise tolerence test a. 60 year old male with cardiac chest pain and high cholesterol b. 60 year old male with cardiac chest pain and a history of smoking c. 60 year old male with cardiac chest pain and symptomatic congestive heart failure d. 60 year old male with cardiac chest pain, a history of diabetes and a BMI of 28 - Correct answerc. 60 year old male with cardiac chest pain and symptomatic congestive heart failure 6. Does anything make your cough better or worse? ● My coughing is worse when the trees shed pollen 7. Are you taking any prescription medications? ● Yes indeed. I brought my list with me here. Lisonopril 10mg daily, HCTZ 25mg daily, glipizide 5mg daily. Also use a CPAP machine, though it’s not really a medicine. 8. Are you taking any OTC or herbal medications? ● Aleve for shoulder pain and Allergra for the allergies 9. Do you have any allergies? ● Sulfa drugs, I am pretty sure im allergic to tree and grass pollen and ragweed 10. Do you now or have you ever smoked or chewed tobacco ● I was a big time smoker in the past. Started when I was 16. A pack a day, but i stopped 10 years ago. That was hard to do. 11. Do you have a problem with fatigue/tiredness ● I sure do. I get tired when i exert. I think im really out of shape, but i also dont sleep great due to sleep apnea, and this makes me tired during the day too 12. Have you been having fevers? ● no 13. Is there any swelling in your ankles? ● Sometimes. Not bad though 14. Do you have a problem with generalized weakness? ● Weakness? No, I dont think i’d call it that really 15. Do you have a cough? ● Not normally, but i have been coughing for the last couple of months 16. Are you coughing up any sputum? ● Occasionally, like now. I get a cold, then bronchitis with coughing up stuff, then it goes away. Sometimes clear. Sometimes not. Its been worse the past 2 months - coughing up this gooey white stuff in the morning. Maybe like a few teaspoons worth. Disgusting. 17. When did your difficulty breathing start? ● About 10 years ago. Past 5 years its affected me more and more 18. Does anything make your difficulty breathing better or worse? ● Sitting still is the best for my breathing. Also it helps if i purse my lips when i breathe out 19. Do you become short of breath with exertion? ● Yes definitely. I can walk slowly to the postbox or from room to room ok, but im out of breath going upstairs to the bedroom or just lifting stuff 20. Are you short of breath at rest? ● Yes just these past couple months 21. Do you have any pain or other symptoms associated with your difficulty breathing? ● Symptoms? Like cough with runny nose. What else do you mean? 22. Has there been any change in your difficulty breathing over time? ● Big time! I used to be able too walk, work, and run with the best of them. But not now 23. Do you have unusual heartbeats / palpitations? ● No. 24. Do you have any pain in your chest? ● No. 25. Can you tell me about any current or past medical problems? ● High blood pressure, sleep apnea, and type 2 DM. Ive had the blood pressure thing for maybe 25 years now. The DM was maybe 5 years ago. But all these are under control. I guess thats all i can think of thats important. 26. Any recent acute or chronic infections? ● No. 27. Any previous medical, surgical, or dental procedures? ● I had my gall bladder removed 20 years ago. I had an accident 30 years back and i had a surgery to fix my shoulder and for the wound in my leg. I guess thats the big stuff 28. Have you ever been hospitalized? ● Just when i had to have some surgery 29. Do you have a family history of heart disease? ● My father died of a heart attack when he was 52. He had HTN and DM and was a smoker. My brother had HTN and heart disease too but passed from cancer 30. Do you drink alcohol? ● A beer with my supper sometimes a couple more when im watching a game 31. Tell me about your work ● Construction… master carpenter, then rose to foreman. I retired at 59. Too tough to continue 32. Does your chest feel tight or heavy? ● No. 33. How severe is your difficulty breathing? ● It seems pretty bad to me. I mean, its affecting my life too much 34. Does anyone in your family have difficulty breathing? ● Not that ive noticed 35. Are you coughing up blood? ● No thank god 36. Do you have a history of lung disease? ● Never evaluated for it, though probably should be. I was exposed to asbestos years ago - and we now know thats bad stuff. Of course there were the usual fumes from stuff around you on the job site, like welding and stuff like that 37. Do you now or have you ever had cancer? ● No thank god 38. Have you had TB? ● Not that ive been told 39. Do you have asthma? ● Not been diagnosed but im starting to think maybe thats whats wrong with me now. 40. Do you have a family history of blood clots in your legs or lungs? ● no 41. Do you have a history of deep vein thrombosis or pulmonary embolism? ● I do have ugly varicose veins. Is that the same thing? 42. Do you have heart disease and/or have you ever had a heart attack? ● Never had a heart attack, but sometimes i worry about it a bit 43. Is there any swelling in your legs? 1. Auscultate lungs- expiratory wheeze bilaterally, possible crackles heard but only able to choose one answer 2. Inspect mouth and pharynx 3. Look up nostrils 4. Visual inspection anterior/posterior chest ( did palpate and percuss also) 5. Auscultation heart sounds- mitral valve regurgitation 6. Visual inspection of extremities 7. Palpate extremities 8. Capillary refill ? 9. BP - 144/92, normal pulse pressure, hypertensive ( the video at the end has his vitals as follows : BP- 145/90 RR20 HR 96 sa02 95%) Ed 10. Eyelid ice pack test 11. Inspect-???? 12. Fundoscopic exam KEY FINDINGS: 1. Dyspnea MSAP 2. Cough 3. BLE Edema +2 4. Bilateral Expiratory Wheezing 5. White sputum production 6. Cobblestoning oropharynx 7. Asbestos exposure 8. Smoking history 40 years one pack a day 9. Sleep apnea 10. Fatigue 11. Elevated BP 12. Use of accessory muscles 13. Hx of HTN and DM controlled Lead diagnosis: COPD Differential Diagnoses: 1. Emphysema 2. Chronic Bronchitis 3. Anemia 4. Pneumonia - community acquired 5. Heart failure 6. Asbestosis 7. Lung cancer 8. Mitral regurgitation?( I would not put that one, I can not find any resources that states it as a differential) 9. Bronchiectasis? ( I agree) 10. Pulmonary embolism? 11. Asthma ? ( i agree) 12. Tuberculosis 13. Pulmonary HTN 14. Myasthenia gravis 15. Lou Gehrig disease? I put the ones below and got 67% (I got 80% by taking out MG, Pneumo Asbestosis, lung cancer, and TB, i think they were ruled out w/ testing) Must Not Miss 1. Emphysema 2. Lung cancer u 3.Heart failure More? 4. Tuberculosis 5. Pulmonary Embolism ALT diagnosis Asthma? Bronchiectasis ? More? Diagnostic tests: 1. CXR PA and lateral $114-$140 2. CBC: $14-$25 3. PFT’s $379-$520 4. 12 lead ECG $118-$188 5. ABG $213 6. BNP $59-$102 7. D-dimer $17-$31 8. Ct chest $350-$450 9. Echocardiogram, transthoracic $1,200-$2,500 10. Alpha 1 antitrypsin $500 11. CTA (not recommended at this time) $1200 12. Troponin I $18-$31 13. Pulmonary ventilation/perfusion scan $487-$1702 15. Stress echocardiogram $1200 16. Cardiac stress test $540 1. CXR PA and lateral 2. CBC · Normal Echocardiogram, TTE · LVH · e/e ratio suggests mildly impaired diastolic relaxation · mild left atrial enlargement · mild aortic stenosis · mildly elevated pulmonary artery systolic pressure at rest (35mmHg) but normal RV size and function Pulmonary Function Test · FEV1 = 1.1 liters (30% predicted) · FVC – 2.5 liters (50% predicted) · FEV1/FVC = .44 (61% predicted) · Diffusing capacity of the lungs for carbon monoxide (corrected for Hgb) = 8.0 ml/min/mmHgb (40% predicted) · After albuterol FEV1 increases to 1.25 liters (an increase of 14%) and FVC increases to 3.0 liters (an increase of 20%) with FEV1/FVC decreasing to .44 (58% predicted) · Lung volumes prior to albuterol show total lung capacity TLC = 5.5 liters (92% predicted) · Residual volume = 3 liters (200% predicted) · Functional residual capacity = 3.5 liters (100% predicted) · Exertional oximetry shows SaO2 dropping to 86% on room air with walking 200 feet with patient complaining of moderate dyspnea Stress echocardiogram · Normal Troponin I · Normal Troponin T · Normal Ventilation/perfusion scan · Normal Chest PA/Lateral · Normal lung volumes · Decreased lung markings in upper lobes · Diaphragms flat · No interstitial or alveolar infiltrates · Heart size upper limits of normal · No effusions · No nodules or masses · No obvious adenopathy . Possible management plan: Final DX: COPD Admit to the hospital Meds: In-office: Duoneb (ipratropium bromide/albuterol nebulizer) 0.5mg/2.5mg per 3mL inhaled q20 min x3 if needed Rx: Albuterol HFA (90mcg/at) Sig: 1-2 puffs q4 hours prn for SOB/wheezing Disp: 1 inhaler Refill: 2 Rx: Umeclidinium-vilanterol 62.5mcg/25mcg per inhalation Sig: 1 inhalation QD Disp: 1 inhaler Refill:0 Rx: Prednisone 40mg tablet Sig: 1 tablet QD x 5 days with food Disp: 5 tablets Refill: 0 Rx: Amoxicillin-clavulanate 875mg tablet Sig4: take 1 tablet PO BID x5 days Disp: 10 tablets Refill: 0 Referrals: Pulmonology and pulmonary rehab, allergist, cardiology, nutritionist (?)