Partial preview of the text
Download NRNP 6560 Midterm Exam (Version-2, 100 Q & A, Latest-2025) / NRNP6560 Midterm Exam: Walden and more Exams Nursing in PDF only on Docsity!
NRNP 6560 Midterm exam ea tisk classes Class 2a: reasonable to perform Class 2b: should be considered Class 3: rarely appropriate General rules for 0G bef feu surgery Stress test not indicated before surgery Do not do prophylactic coronary revascularization Meds before oe ok Discontinue biguanides, alpha glucosidase inhibitors, thiazolidinediones, sulfonylureas, and GLP-1 agonists - Do not start aspirin before surgery - Stop Warfarin 5 days before surgery. May be bridged with Lovenox. - Do not stop statin before surgery - Do not start beta-blocker on day of surgery, but may continue Assessment of aes tisk uncontrolled HTN, severe valvular disease), concern with CAD, CHF. arrhythmia, CVD - patient stable or unstable? - urgency of the procedure (oncology will be time sensitive) - risk of procedure - nutritional status - immune competence - determine functional capacity (need to be more than 4 METS, more than 10 METs makes low risk) Low risk surgeries breast biopsy cystoscopy, vasectomy laporascopic procedures Plastic surgery intermediate risk “ali nes thyroidectomy Intraperitoneal Prostate Laminectomy Hip/ knee Hysterectomy cholecystectomy nephrectomy non majot intrathoracic at tisk ee transplants spinal reconstruction peripheral vascular surgery Lee's revised cardiac risk index High risk surgery = 1 CAD=1 CHF =1 Cerebrovascular disease = 1 DM 1 on insulin = 1 Creat greater than 2=1 1=lowrisk 2 = moderate risk 3 = high risk SCIP Boerne infection measures incision - be selected for activity against the most probable antimicrobial contaminants - be discontinued within 24 h after the surgery end-time ate infection reduction methods - wash hands - normothermia - maintain euglycemia - urinary catheters are to be removed within the first two postoperative days Osteoarthritis: what, incidence collagen which causes inflammatory changes Rheumatoid arthritis: what, who connective tissue, first that of jionts them other soft tissues (renal, cardiovascular, pulm). TNF-alpha plays a big role - more women than men - unknown cause - Epstein Barr virus Rheumatoid arthritis: viet and fuse pain - weakness, fatique - anorexia, weight loss - generalized malaise - swollen joints/ boggy feeling of joints with deformity of joints - warm, red skin on affected joints later: - pleural effusions and pulmonary nodules - inflammation of sclerea (scleritis) - pericarditis, myocarditis - splenomegaly (Felty's syndrome) - anemia (hypochromic, microcytic) with low ferritin - possibly: positive rheumatoid factor - XR: joint swelling, later cortical and space thinning - synovial fluid: yellow, thick with elevated WBC up to 100.000 Felty's syndrome Rheumatoid arthritis treatment Correct answer- - early treatment better than stepwise - early referral rheumatologist - disease-modifying anti-rheumatic drugs (DMARDs): - methotrexate ( no alcohol, monitor renal and liver, give with folic acid) - cyclosporine - Gold preparations (can cause thrombocytopenia) - Hydroxychloroquine: antimalarial drug (may cause visual changes, monitor) - sulfasalazine, moderate RA - Leflunomide, moderate to severe RA - Etanercept - monitor liver function with DMARDs - screen for TB (skin test) and Hep B - surgery: joint debridement, joint replacement Gout: what, who blood and synovial fluid causing crystallization which causes inflammation (Type A and Mediterranean) - impaired renal function which causes excess uric acid - foods high in purine, such as dairy, red meat, shellfish, beer Out findings, diagnostics - pain at night - flank pain because of renal calculi - fever - leukocytosis - elevated erythrocyte sedimentation rate - tophi (bump under skin) on ear - limited joint motion - elevated serum uric acid (greater than 7ma/dl) - urate crystals seen with joint aspiration - xr joint erosion and renal stones Gout treatment Correct answer- - NSAIDS: naproxen, ondomethacin, sulindac - Colchicine for those who do not tolerate NSAIDS (caution with renal impairment). Also for prophylaxis - Corticosteroids, if NSAIDS and colchicine not tolerated - 24hr urine for uric acid - Allopurinol after flare is over (LOOmg PO daily) - Biological modifiers of disease (BMD): Pegloticase. Not for asymptomatic. Treat with prophylaxis first. Monitor serum uric acid ANA. Tests in rheumatic disease: what, normal level, abnormal with. Normal: Titer 1.32 POsitive with: Sjogren's (SS), SLE (lupus), c4 foot snewer, Tests in rheumatic disease: what, normal level, abnormal with. response Normal: men: 12-72. Women: 13-75 mg/dl Increased with: inflammatory disease Decreased with: RA, lupus, SS The radioallergosorbent test (RAST). Tests in rheumatic disease: what, normal level, abnormal with. normal: 0.01 - 0.04 mg/dl Loose ligaments Ehlers-Dantos syndrome (loose ligaments and overflexible joints- congenital) Findings and diagnostics subluxation Correct answer- Pain over affected area previous subluxation swelling around joints loss of ROM R, CT, MRI show subluxation Increased WBC (stress response) Management of subluxation Correct answer- Early reduction, many spontaneously immobilization (splint, sling) PT NSAIDS for pain/ swelling Dislocation: what, cause Correct answer- Complete displacement of bone end and position in joint. Common sites: shoulder, elbow (nurse maid), wrist, hip, knee (emergency if loss of integrity of ACL and PCL), ankle/ foot high energy blunt force trauma congenital neuromuscular disorder inflammatory joint disease, RA Loose ligaments younger than 35 often, due to sports Often associated with fracture Findings and diagnostics dislocation Correct answer- severe pain over affected area hx of mechanism of injury numbness/ tingling distal to injury joint deformity shortened limb contusion/ laceration over affected joint decreased pulses distal to joint decreased rom decreased sensation distally due to nerve damage WBC elevated due to stress Hgb may be low due to bruising xr: dislocation (should get anteroposterior) CT scan for pelvic trauma to rule out hip/ pelvic fracture Order ultrasound for posterior knee dislocation: high incidence of popliteal artery injury McMurray test, Lachman Test, straight leg test Correct answer- McMurray: turn foot and bend knee. Positive with Meniscus injury Lachman test: Hold upper and lower leg, around knee, stretch. Hyperstretch: ACL injury Straight leg test: Pain when raising leg, while supine. Positive for herniated disk. Dislocation management Correct answer- Early reduction is essential: closed/ manual if no fracture. If fracture then may need surgery. Postreduction immobilization (splint, cast, sling) surgical repair of ligaments PT/ OT NSAIDS. Muscle relaxant for muscle spasms Narcotics for short term use Soft tissue injury: definition, classifications, incidence Correct answer- Injury to non-bony tissue, such as muscle, ligament, tendon, bursa, cartilage, skin Classification: - Closed injury: contusion, hematoma, crush, strain (muscle), sprain (ligament, first to third degree), rupture (muscle and ligaments: instability, inability to move) - Open injury: laceration, abrasion, penetrating/ puncture, amputations trauma exercise/ overuse autoimmune (RA, SLE) obesity age (skin tear elderly) Findings and diagnostics soft tissue injury Correct answer- pain swelling feeling of instability of joint Ruptures/ muscle tear: decreased ROM, immediate swelling and hematoma, abnormal contour muscle, instability of joint, pain/ guarding, watch neurovascular integrity Ligaments/ sprain: pain on palpation and ROM, decreased ROM with moderate swelling, Lachman's test (hypermobile joint is positive sign) Strain/ muscle or tendon: swelling, decreased/ absent ROM, pain/ guarding Salter-Harris Fracture Classification Correct answer- Concerns growth plate S: straight across growth plate A: Above growth plate L: BeLow growth plate T: Through growth plate R: ERaser of growth plate (Rammed) Cause of fractures Correct answer- Trauma, tumor, osteoporosis, drugs (prednisone), nutritional deficiency (Vit D), neuromuscular disorders Findings and diagnostics of fractures Correct answer- Pain History of traumatic event Neuromuscular dystrophy: headache (autonomic dysreflexia) Deformity of limp Diminished/ absent pulses ecchymosis and swelling xr, always order anteroposterior and lateral CT scan for pelvic and spinal fractures MRI for suspected spinal cord injury Mortise view (leg inward) for ankle to check talus bone oblique films for humerus, femur, ankle DEXA scan to determine degree of osteoporosis Acute Fractures Management Correct answer- - ABC care (Airway, breathing, circulation), musculoskeletal second survey - fluid resuscitation - early reduction of fracture - cover apen wounds - surgical irrigation and debridement for open fracture - Ab's: Cefazolin for gram pos. Clindamycin for tetani infection - pain: opioids - tetanus shot of unknown - calcium upon discharge for osteoporosis - cement injection in bone with vertrebroplasty Fractures: Reduction Correct answer- - Orthopedic surgeon referral - buddy-tape toe fracture for immobilization - radius/ ulna: splint with ace-wrap, unless open - post reduction xr - check neurovascular function pre and post reduction - intramedullary rodding for closed femoral and tibial fracture - external fixation for open fracture Compartment syndrome: what, who Correct answer- Increased pressure in tissue limits the circulation and function of the contents within that space (compartment: bone, blood vessel, netves, muscle, soft tissue). Most often in arms and legs (most compartments), also abdomen Men under age 35 stemming from fracture of tibia stemming from splint, cast, scar increased swelling due to hemorrhage, coagulation disorder, infiltrated iv site, trauma/ surgery, burn, bite Compartment syndrome finding and diagnostics Correct answer- pain out of proportion to injury hx of trauma paresthesia heaviness in affected extremity Six P's: Pain on passive stretch Paresthesia Paralysis of affected limb (late finding) Pulses, bounding first then pulseless later Pallor of affected limb Polar/ poikilothermia (ice cold limb) Elevated WBC Hyperkalemia (tissue necrosis) CPK and LDH elevated Myoglobin in urine Elevated compartment pressure (normal 0-8) Clinical diagnosis, MRI may confirm Acute renal failure (due to myoglobinuria) Compartment syndrome management Correct answer- Non surgical: - limb at heart level (do not elevate) - remove bandages/ immobilizers - diuretic - neurovascular checks - CRRT/ dialysis to treat ARF - intracompartmental pressure monitoring Surgical: - fasciotomy, with delayed closure of wounds (negative pressure wound vac) - skin grafting - amputation if septic from necrotic tissue - Trauma - Obesity/ sedentary lifestyle -Age 35-45 - Often located at L4- L5,L5-S1 Herniated disk findings and diagnostics Correct answer- - Decreased/ absent reflexes - Atrophy of muscles - limp - possible straight leg raise test/ radiculopathy - limited rom spine - xr anteroposterior and lateral of spine - CT with and without dye: detects bony defects - MRI: detects soft tissue defects - myelogram - EMG (tests nerve innervation) Herniated disk L4 root finding (disk between L3 and L4) Correct answer- - quadriceps weak, difficulty extending quadriceps (have pt squat and rise) - pain and numbness radiating into medial malleous - diminished/ absent knee jerk Herniated disk L5 root finding (disk between L4 and L5) Correct answer- - dorsiflexion of great toe and foot weak (have pt walk on heels of feet) - pain and numbness into lateral calf and between first toe web space Herniated disk S1 root finding (disk between L5 and S1) Correct answer- - weakness of plantar flexion of great toe and foot (have pt walk on toes) - pain along buttock, lateral leg and lateral aspect of foot and posterior calf - diminished achilles calf Herniated disk management Correct answer- Non surgical: - functional bracing -rest - PT for muscle strengthening - heat/ ice alternate - weight loss - transcutaneous electrical nerve stimulator - NSAIDS. - antispasmodic - Narcotics for short-term use - epidural steroid injection Surgical: - Laparoscopic diskectomy - hemilaminectomy - total disk replacement arthroplasty HIV and age Correct answer- - Can live beyond 50 years, but survival decreases after 45 yrs, unless tested. - Antiretroviral meds are approved for younger than 5Oyrs, so older pt's need close monitoring HIV etiology Correct answer- Africa/ Asia: heterosexually acquired Western nations: men who have sex with men, iv drug user, congenital spread Pathophysiology of HIV Correct answer- - HIV infects cells with CD4 receptor (macrophages, Tcells). Acute infection (high viral load) then latent (lower viral load). When CD4 is less than 200 AIDS and viral load increases again, this immunodeficiency - HIV is chronic and prgressive: HIV - acute retroviral syndrome, symptoms Correct answer- fever, chills fatique diffuse erythematous rash HIV test may be negative, based on how long since infection HIV viral load increased, CD4 within normal range HIV - latent phase Correct answer- - asymptomatic - may have persistent lymphadenopathy - HIV load and CD4 load variable (ultimately HIV load high, CD4 low) Symptomatic HIV disease Correct answer- Symptoms: fever, chills, diarrhea, weight loss - infections: candidiasis/ thrush (oral, mucocutaneous, vaginal), shingles (herpes zoster), frequent bacterial infections AIDS, definition and diagnosis Correct answer- acquired immune deficiency syndrome CD4 low, below 500 and infection with opportunistic organism or: CD4 below 200 Common oppertunistic organism in AIDS Correct answer- Pneumocystis jiroveci Cryptosporidium Candida albicans Advanced HIV infection: definition, symptoms, prognosis Correct answer- CD4 below 50 wasting, fevers, fatigue - Pneumocystis jiroveci (sudden rapid decline CD4): Trimethoprim- sulfamethoxazole neb. Stop if CD4 above 300 - Toxoplasmosis: when CD4 less than 100. Trimethoprim- sulfamethoxazole plus. pyrimethamine. Dc if CD4 above 200. - Mycobacterium avium. Cd4 below 50. Zithromax or clarithromycin Recommended vaccines for HIV Correct answer- - Hep B, if Hep B antigen neg - Inactivated flu vaccine (assess viral load and do not give live vaccine) - Hep A, liver disease risk, iv drug use, MSM - Pneumococcal vaccine - Tdap (instead of Td) - Varcella Zoster for elderly Test for HIV with following infections Correct answer- - candidiasis of esophagus/ trachea/ bronchi/ lungs - extrapulm cryptococcus - invasive cervical ca - cryptosporidiosis with diarrhea - CMV - Herpes simplex lasting longer than 1mo - Lymphoma brain, in younger than 60 - Kaposi sarcoma, younger than 60 - Mycobacterium TB - Pneumocystis jiroveci pneumonia - CD4 less than 200 Giant cell arteritis, definition and etiology Correct answer- Inflammation of the medium and large arteries, often temporal artery or aorta, represents polymyalgia rheumatica - adults older than 50 - more women than men - most will also have polymyalgia rheumatica - at risk for aortic aneurysm polymylagia rheumatica Correct answer- Medical emergency because temporal arteritis can lead to blindness and aortic arteritis can cause aortic occlusion - pain, stiffness in shoulder and pelvic girdle region - malaise weight loss, fever - headache, jaw claudication, scalp tenderness, throat pain Giant cell arteritis findings Correct answer- - headache - jaw pain - visual impairment - throat pain - arm claudication - difficulty talking - fever - enlarged and tender temporal artery - blindness CT: arterial narrowing WBC normal ESR elevated CRP elevated Gold standard: biopsy of affected artery Giant Cell arteritis treatment Correct answer- Prednisone, do not wait for biopsy IV for 3 days when vision loss Oral for 6 wks to 2mo systemic lupus erythematosus (SLE) Correct answer- Chronic, inflammatory, autoimmune disorder that affects multiple body systems, caused by trapping of antibodies in capillary and visceral structures, destructing host cells. Exacerbations/ remissions systemic lupus erythematosus (SLE), incidence Correct answer- - drug-induced; hydralazine, methyldopa, quinidine, chlorpramazine, isoniazid - triggers for malfunctioning of T and B cellsL sex hormones, UV radiation, infection, stress - mostly women - mostly African-American - familial risk systemic lupus erythematosus (SLE), findings Correct answer- - joint symptoms without synovitis - fever, malaise, weight loss, anorexia - skin lesions - oral and nasal ulcers - ocular changes - HF; myovcarditis, pericarditis, cardiac arrhythmia’s, htn - pleural effusions, pneumonia, pleurisy - CKD - abd pain - cognitive impairment, depression, stroke, seizures ~ serum antinuclear antibody present in all pt's but not specific - no specific diagnostic test - may be abnormal: anemia, leukopenia, thrombocytopenia, positive coombs, proteinuria, hematuria, false/ pos for syphilis systemic lupus erythematosus (SLE), treatment Correct answer- - supportive, not curative - Started before or after transplant for up to 2 wks to delay first rejection episode - maintenance for live of graft - caution with conversion between generic and brand forms of cyclosporine - Calcineurin inhibitors metabolized via cytochrome P450 enzyme, so may alter other drig concentratior - avoid grapefrui ice when on calcineurin inhibitors (may cause increase) Common medical complications in organ transplantation Correct answer- HTN Calcium channel blockers often used to treat. Usually multiple agents necessary. Avoid hypotension in kidney recipient. Posttransplant diabetes mellitus May be related to corticosteroids. Increases risk for graft loss. Tight glycemic control indicated. Renal insufficiency Nephrotoxicity from meds (Calcineurin inhibitors). Treatment: reduce Calcineurin inhibitors dose, limit other nephrotoxic meds Hyperlipidemia From effect of immunosuppresive meds on lipid levels (mostly from sirolimus). Optimize pharm cholesterol management Bone disease Osteoporosis common, related to corticosteroid. Baseline and annual bone scan necessary. Minimze corticosteroid use, give calcium Malignancy Increased incidence of lymphoma, skin ca, Kaposi's sarcoma. Related to Epstein-Barr and high doses of cyclosporine and tacrolimus. Treat: minimize immunosuppression, start radiation. Poor prognosis. Calcineurin inhibitors: which, indication, adverse effects Correct answer- Tacrolimus Cyclosporine Prophylaxis of rejection T: tremor, renal dysfunction, hyperglycemia C: tremor, renal dysfunction, hin, hirsutism, gingival hyperplasia mTOR inhibitors: which, indication, adverse effects Correct answer- Sirolimus Everolimus Prophylaxis of rejection S: edema, rash, hyperlipidemia, abd pain, nausea, diarrrhea, trombacytopenia, fever E: htn, edema, rash, hid, thrombicytopenia, hyperglycemia, elevated LFT's, fatigue, fever Corticosteroids: which, indication, adverse effects Correct answer- Prednisone Solumedrol P: Prophylaxis of rejection S: Induction, treatment and prophylaxis of rejection Fluid retention, hyperglycemia, impaired wound healing, peptic ulcer Infections in organ recipients: general thoughts and types Correct answer- - infections are leading cause of death - Increased risk 6 mo post transplant - fever and wbc count not as pronounced because of immunosuppressive meds. Viral: CMV, cause of morbidity and rejection Requires frequent monitoring Prophylaxis with ganciclovir is recommended Fungal: Candida in postiver, Aspergillus in post-lung Oral fluconazole for fungal prophylaxis or Trimethroprim-sulfamethoxazole (bactrim) for pneumocystis prophylaxis Bacterial: Most common infections Intra-abd infections for liver, pancreas and intestinal transplant Pneumonia for heart and lung transplants UTI for renal and pancreas transplant organ recipient and vaccinations Correct answer- - Should receive flu vaccine, but not live vaccine - Up to date on vaccines before transplantation - no live vaccines and avoid household members post live vaccine vaccination kidney transplantation, incidence and complications Correct answer- ESRD, creat clear less than 15mi/min Surgical: Graft thrombosis, 2-3 days post-op. Thrombosis with loss of urine or hematuria. Diagnosis with renal us. Will cause graft loss. Urine leak: 
