NUR 265 Advanced Concepts of Medical–Surgical Nursing
Exam 4
Question:
Lyme Disease: Hallmark sign
Answer:
stage 1: "bulls eye rash" and flu-like symptoms
Stage 2: facial paralysis, carditis, meningitis
Question:
Lyme Disease: Assess
Answer:
Skin history of tick bites
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Question:
Lyme Disease: Interventions
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
Question:
Allergic Reaction Priority
Answer:
STOP THE INFUSION/ELIMINATE the trigger, then STOP the immune response
Give Epi maintain airway
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Question:
Latex allergy: risks
Answer:
-frequent use of latex condoms -healthcare workers -allergy to avocados, bananas, and some nuts
Question:
Anaphylactic shock
Answer:
AIRWAY--give epi IV or IM STAT and intubate if needed BREATHING--apply O2; mechanically ventilate CIRCULATION--monitor for distributive shock; give fluids
Question:
Epinephrine Auto-injector teaching
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.
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Question:
Immunocompromised Patient
Answer:
-Do not drink anything that has been sitting out -take temp at least once per day -clean toothbrush once weekly in dishwasher 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
Question:
HIV: Assess
Answer:
CD4 count ELISA test once per year for at risk patients
Question:
HIV: Interventions
Answer:
PREVENTION:
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