NUR 265 EXAM 4
Lupus: Hallmark sign Correct Answer: butterfly rash on face
Lupus: Indication of flare Correct Answer: Fever and fatigue
*also assess BUN function
*c reactive protein remains normal
Lupus: Interventions Correct Answer: -Falls precautions
-treat pain with tylenol and...
Scleroderma: Interventions Correct Answer: aspiration precautions (keep HOB at 60 degrees during
meals and after)
skin protection measures
small frequent meals--avoid caffeine and alcohol
-avoid spices, caffeine and pepper
Lyme Disease: Assess Correct Answer: Skin
history of tick bites
Lyme Disease: Interventions Correct Answer: prevention!
Insect repellant with DEET
early stage--doxycycline antibiotics ORAL
late stage--Iv antibiotics (ceftriaxone)
avoid tall grass
wear light colored clothing
have pets wear tick collars
Allergic Reaction Priority Correct Answer: STOP THE INFUSION/ELIMINATE the trigger, then STOP the
immune response
Give Epi
maintain airway
Latex allergy: risks Correct Answer: -frequent use of latex condoms
-healthcare workers
-allergy to avocados, bananas, and some nuts
Anaphylactic shock Correct Answer: AIRWAY--give epi IV or IM STAT and intubate if needed
BREATHING--apply O2; mechanically ventilate
CIRCULATION--monitor for distributive shock; give fluids
Epinephrine Auto-injector teaching Correct Answer: always carry 2 devices
inject by "stabbing" into top of thigh with pants on (AVOID pockets)
call 911 immediately--patient still needs to be monitored
keep epi in cool dark place.
Immunocompromised Patient Correct Answer: -Do not drink anything that has been sitting out
-take temp at least once per day
-clean toothbrush once weekly in diswasher or bleach solution
-do not eat raw foods; salad, cottage cheese
-do not scoop litter boxes
-no plants or soil exposure
-antibacterial soap
, -AVOID reptiles
HIV: Assess Correct Answer: CD4 count
ELISA test once per year for at risk patients
HIV: Interventions Correct Answer: PREVENTION:
-condoms
-PreP (truvada) must take 4 consecutive days in a row before protected; cant miss more than one dose
in a row
-needle safety
-post exposure prophylaxis-start cART within 24-36 hours of exposure
HIV: Nutrition Correct Answer: high calorie
high protein
low fat
small frequent meals
thrush--treat with anitfungal
HIV tx: HAART/cART Correct Answer: DOES NOT CURE
Does not prevent secondary/opportunistic infections
MUST TAKE 90% of the time --otherwise resistance will occur
HIV: complications --- AIDS Correct Answer: CD4 count less than 200mmhg
most likely to experience opportunistic infections
--I.e Pneumocystic jiroveci pneumonia (ASSESS AIRWAY!!)
consult pallative care/hospice
candida albicans Correct Answer: -Hallmark sign-- white patches in the mouth
-"food doesnt taste right"
-If patient wants a coke they can have it! They just have to rinse mouth out with water (fungus loves
sugar)
tuberculosis Correct Answer: hallmark sign-- night sweats, high fever, cough
-airborne isolation
-do not trust TB skin test in client with HIV
External Radiation Correct Answer: -teach client to leave markings in place
-use sunscreen
-wash skin with mild soap and use lotion frequently
Breast Cancer: Risks Correct Answer: -BRCA 1&2 genes (preventative mastectomy)
-women age 65-80
-elevated estrogen levels
-alcohol consumption
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