NRNP 6560 FINAL EXAM LATEST 2023-2024 VERSION 1 EXAM 100 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) WALDEN UNIVERSITY

coup-contrecoup injury
Dual impacting of the brain into the skull; coup injury occurs at the point of impact; contrecoup injury occurs on the opposite side of impact, as the brain rebounds.

Scalp laceration: what, effect, management
Primary head injury

profuse bleeding – signs of hypovolemia

Apply direct pressure
Suture/ staple laceration
Lidocaine 1% with epi to control bleeding, not close to nose/ ears

Skull fracture: types, effect, management
Primary head injury

Simple: no displacement of bone. Observe and protect spine

Depressed: bone fragment depressing thickness of scull
Surgery for debridement. Give tetanus and seizure precautions

Basilar: fracture at floor of skull
Raccoon eye – periorbital bruising
battle’s sign: mastoid bruising
otorrhea/ rhinorrhea – halo sign: do not obstruct flow
Give Ab’s
Oral intubation and oral gastric instead of nasal

Brain injury: types, effect, management
Primary head injury

Concussion: reversible change in brain functioning
loss of consciousness, amnesia
Do not give opioids, admit for unconsciousness greater than 2min

Contusion: bruising to surface of brain with edema
Frontal and temporal region
Brainstem contusion: posturing, variable temp, variable vital signs
N/V, dizziness, visual changes
seizure precautions

Hematoma – neuro: types, effect, management
Epidural hematoma: commonly temporal/ parietal region with skull fracture, causing bleeding into epidural space
Loss of consciousness
Rapid deterioration: obtunded, contralateral hemiparesis, ipsilateral pupil dilation
CT scan (non contrast)
Treatment based on Brain trauma foundation. Surgical if greater than 30cm

Subdural hematoma
most common type of intracranial bleed
Acute (hours): drowsy, agitated, confused, headache, pupil dilation,
CT scan (noncontrast)
surgery for 10mm thickness or 5mm midline shift or for worsening GCS
Chronic (days): headache, memory loss, incontinence
CT scan (noncontrast)
Surgery: burr holes/ crani

Cerebral edema/ ICP elevated/ herniation: symptoms, management
decreased level of consciousness
Blown pupil
Cushing triad: HTN (widening pulse pressure), decreased resp rate, bradycardia (means increased intracranial pressure)

Neuro exam components
AVPU: awake, response to verbal stimuli, painful stimuli, unresponsive

GCS: 8 or below is comatose

Posturing:
decorticate = arms, legs in
decerebrate = arms, legs out

Electrolyte imbalances in brain injury
Hyponatremia: SIADH and cerebral salt wasting
Hypernatremia: DI (give mannitol)

Management of traumatic brain injury

Consult neurosurgery
Limit secondary injury
Prevent hypotension (syst 90) and hypoxemia (PaO2 60). May give blood to improve tissue perfusion.
Treat cerebral edema: elevate bed, sedate, paralyse, mannitol, hyperventilation (PaCO2 25-30), during first 24hrs.
sedation and analgesia: opioids to reduce ICP (Fentanyl) with propofol. Could give Nimbex or Vec. to help oxygenate/ ventilate
steroids: avoid
Give mannitol or hypertonic saline for herniation: bolus then gtt. monitor serum osmolality, sodium, and bp.
Seizure precautions: give phenytoin or keppra
DVT prophylaxis: stockings, LMWH
head injury means spine injury until proven otherwise
hypothermia: can control ICP (89 – 91F)
decompressive crani: ICP refractory to tx
brain O2 monitoring (jugular vein O2 sats)

ICP monitoring
For: GCS 3-8 with abnormal CT and comatose pt’s with normal CT and older than 40, posturing, hypotension.

Normal value: 5-10 mmHg

Recommend initiating treatment if ICP > 20 mmHG.

Can calculate CPP (CPP = MAP – ICP). Should be 60

Brain death criteria
Must have all:
No spontaneous movement
Absence brain stem reflexes (fixed/ dilated pupils, no corneal reflexes, absent doll’s eyes, absent gag, absent vestibular response)
Absence breathing drive/ apnea

can’t be declared brain dead when: hypothermia, drug intoxication, severe electrolyte/ acid-base imbalance

EEG, CTA of brain, Cerebral angiography, transcranial doppler

Spinal cord trauma: cause and who

MVA, falls, acts of violence, sports, wounds
Rapid acceleration/ deceleration causes hyperextension (fall, rear-end collision)(central cord syndrome), hyperflexion (bilateral facet dislocation), vertical column loading (compression and then shattering from falls/ dive lands on butt, at C1 from diving), whiplash
Distraction injury: from hanging
penetrating trauma: from wound
pathologic fractures (osteoporosis/ cancer)

mainly cervical spine. High mortality.
More common in men
more common in young than old

Fractures and vertebrae
Cervical: C1-C7. Flexible and small diameter so many fractures

Thoracic (T1-T12): connected to ribs. Not common in fractures

Lumbar: L1-L5: Very mobile, requires great force to fracture

Sacral

Spinal cord trauma assessment

History: mechanism of injury, pt’s complaints, pre-hospital tx
Physical assessment: treat airway, breathing, circulation (ABC) first. Pulm complication common in quadriplegia. Assess respiratory status: injury above C3 is resp arrest. C5 – C6 spares diaphragm so breathing exists.
grade strengthening (0= no muscle contraction, 5 = full strength)
complete lesion: pt lacks all function below level of spinal cord damage. Poor prognosis.
incomplete lesion: parts of spinal cord intact
sensory function: start at no feeling then go to feeling
evaluate back (log-roll)

Motor assessment in spinal cord trauma
If unable to do, # above:

Deltoids (C4): shrug shoulder
Biceps (C5): flex arm and push arms away
Wrist (C6): try to straighten wrist while pt tries to flex
Triceps (C7): extend arm and try to bend while pt prevents that
Intrinsic (C8): fan fingers and push together
Hip flexion (L2 – L4): bend knee and apply pressure
Knee extension (L2-L4): extend knee with hip/ knee flexed

key signs of spinal cord injury – various levels
C2-C3: resp paralysis, flaccid paralysis, deep tendon reflexes loss

C5-C6: diaphragmatic brething, paralysis of intercostal muscles, quadriplegia, anaesthesie below clavicle, areflexia, fecal/ urinary retention, priaprism

T12-L1: paraplegia, anesthesia legs, areflexia legs, fecal/ urinary retention, priaprism

L1-L5: flaccid paralysis, ankle/ plantar areflexia

Multisystem impact of spinal cord injury
Cardiovascular:

hypotension/ spinal shock. Fluid resuscitation (LR)
bradycardia; oxygenate well, normothermia, atropine
vasovagal reflex: limit suctioning length
Poikilothermy
venous thrombosis: dvt prophylaxis
orthostatic hypotension

GI:

abdominal injuries: assess for abd distention
curling’s ulcer: stress ulcer. Give ranitidine
gastric atony and ileus: NG to LIS
loss of bowel function: initiate bowel program

GU:

autonomic dysreflexia: HTN crisis from distended bladder or other noxious stimulu. Decompress bladder.
UTI

Musculoskeletal:

paralysis
wounds

Psychological:

ineffective coping, powerlessness, denial/ anger/ depression. Be honest with positivity, include pt, interdisciplinary approach

Spinal cord lesions/ syndrome
Anterior cord syndrome: weakness/ paralysis with loss of sense of pain and temp

Posterior cord syndrome: can’t feel touch and vibration

Central cord syndrome: greater loss in upper extremities than lower

Brown sequard syndrome: one side of spinal cord is damaghed by stab/ gun wound. Ipsilateral motor loss and contralateral loss of pain and temp sense. Extremities that can move have no feeling and that have feeling can not move.

Spinal cord injury: diagnostics
Cervical vertrebrea: lateral xr, then AP (swimmer view)

Thoracic vertebrae: lateral and AP xr, view all 12

Lumbar: lateral and AP, view all 5

CT to check for bony fragments

Films in flexion. extension to check for fractures

Myelogram: detects compression of cord by herniated disks, bone or foreign matter

MRI: cord impingement, hematoma, infarct, contusion, hemorrhage.

Spinal cord management

Consult neuro
Airway maintenance (do not hyperextend neck when intubating)
immobilization (cervical collar/ spine board)
intravascular fluid (neurogenic shock: warm, dry, brady)
monitor bp (avoid hypotension: keep MAP 85)
Foley
NG
AB for penetrating injury
room temp
good skin care
fixation of spine
fusion: attaching injured vertebrae

Key features of dementia

General decrease in level of cognition – thinking, memory, reasoning
Behavioral disturbance
Interference with daily function and independence

Not a disease, but group of symptoms by various diseases

Alzheimer’s disease
most common form of dementia

Neuritic plaques, neurofibrillary tangles, degeneration of cholinergic neurons causing irreversible neuronal damage. B-amyloid present in high levels. Effect: cerebral atrophy.

Causes of brain degeneration
Alzheimer’s
Parkinson’s
Huntington’s
Vascular: stroke, arteritis
Infectious: HIV, Syphilis, Meningitis, Encephalitis
CNS/ toxic: drug overdose
Nutritional deficiency: Vit B12, folate deficiency
Chronic seizures
Lewy body dementia

symptoms of dementia

Slow onset
memory loss and confusion
problems with language
impaired abstract reasoning
aphasia, apraxia, agnosia
disorientation
poor judgement
emotional problems
sleeplessness

Dementia labs/ diagnostics

History: family/ spouse report
Physical: neuro, cognitive examz: Mini mental State exam (score 23 or less is cognitive impairment), document in 3-6mo intervals
Labs: glucose, electrolytes, magnesium, calcium, liver tests, BUN/ creat, thyroid, Vit B12, HIV, CBC, ABG, cultures, drug screen
CT head/ MRI: for tumor/ infarction
PET scan: differentiate dementia type
EEG
Lumbar: rule out meningitis, neurosyphilis
XR chest: rule out CHF, COPD
ECG
Identify treatable cause

DSM-V criteria for dementia

Memory impaired
At least two of these: aphasia, apraxia, agnosia, disturbance in executive functioning
Disturbance of one or two of these disrupts functioning
Disturbance not only during delirium

Dementia management

supportive: living situation
treat underlying illness
stop nonessential meds
maintain nutrition
avoid restraints, except for safety
address safety issues
cholinesterase inhibitors can improve symptoms mildly (because of cholinergic deficiency)
Alzheimer’s related: meds very mild and temporary effect

Medication for dementia
Mild to moderate Alzheimer’s:

Donezepil 5mg, then 10mg after 4-6 wks. Can cause syncope, brady, AV-block, N/V, weightloss
Rivastigmine. With food, can cause hypotension, syncope
Galantimine, 4mg for 4 wks, then 8mg 4 wks, then 12mg. Avoid in renal and liver failure

Moderate to severe dementia:

Memantine (N-methyl-d-aspartate rec anatgonist), prevents progression. May be paired with donezepil. May cause Stevens-Johnson’s

For aggression:

Olanzapine (Zyprexa), Quetiapine (Seroquel), Risperidone, Ziprasidone. Short term. May cause tardive dyskinesia
Haldol may help too for unmanageable aggression.
Benzo’s: Clonazepam. May cause paradoxical aggression. Lorazepam

For emotional lability:

Imipramine
Setraline
Zoloft
Citalopram

multiple sclerosis
Disease with myelin sheath destruction causing disruptions in nerve impulse conduction.

Acquired, immune-mediated.

Relapses/ attacks/ exacerbations and remissions

Etiology of MS
More women than men
Caucasians, more northern European
Early onset, 20-40ies
Measles, Herpes, Chlamydia, Epstein-Barr

Classification of MS
Relapsing – Remitting:
Clear/ defined episodes of relapse and recovery. No progression between episodes and return to baseline. Most often initial presentation.

Secondary progressive:
As Relapsing- Remitting, but then progression between episodes. No return to baseline.

Primary progressive:
Continued disease progression. Minor improvements. Usually after 40yrs.

Progressive relapsing.
Progressive disease with relapses, and progression in between.

Malignant MS:
rapid onset, rapid deterioration

Benign MS: No deterioration after 10 yrs

MS symptoms
Subjective:

Motor weakness, stiffness
Numbness, tingling, burning, pain
double vision, dysarthria, dysphasia, vertigo (brain stem)
visual deficits
gait ataxia, tremor, uncoordinated movements (cerebellum)
cognitive dysfunction: memory, processing
fatigue (common!)
sleep disorder
bladder, bowel dysfunction
seizures

Objective:

decreased sensation of pinprick, vibratory, temp
Reflex changes: abnormal deep tendon, pos babinski, pos hoffman’s
brain stem changes: nystagmus, hearing loss, tinnitus
Cerebellar: ataxia, tremor, poor coordination
visual field changes
frontal lobe: cognitive dysfunction, emotional changes

MS diagnostics

neuro exam
MRI (white matter lesions, lesions spinal cord, T1 and T2 lesions) (diagnostic!)
CSF analysis: elevated igG and oligoclonal bands in CSF but not serum

MS management

consult neuro
no intervention for mild attack
Acute intervention for relapse with Glucocorticoid (po or iv)
symptom management meds
disease modifying meds: to reduce relapse, delay disability, and decrease MRI lesions:
Fingolimod. For relapsing. May cause brady, AV-block, HTN, diarrhea
Betaseron. For relapsing. May cause depression/ suicidality
Avonex. For relapsing. May cause flu-like symptoms
Rebof. For relapsing. May cause flu like symptoms
Glatiramer acetate. For Relapsing/ remitting.
Mitoxantrone. For sec progressive, progressive, or worsening relapsing/ remitting.

Parkinson’s disease: what, etiology
Neurodegenerative disorder caused by depletion of dopamine-producing cells causing resting tremor, rigidity, slowness of movement.

Age onset: 60
more men than women
caucasians
Environmental (metals such as copper) and genetic factors. Gene: PARK1

Symptoms and diagnostics of Parkinson’s

Classic triad: resting tremors, rigidity, bradykinesia
Motor symptoms: postural instability can cause falls
Classic gait: diminshed arm swing, shuffling steps, bent forward, frozen gait
neuropsychiatric: depression, dementia, anxiety, psychosis, sleep disruption
autonomic dysfunction: urinary incontinence, sexual dysfunction, constipation, impaired thermoregulation
Craniofacial: masked face/ expressionless, dysphagia, impaired sense of smell, drooling
H&P
CT and MRI to assess for differential

Parkinson’s treatment

consult neuro
Pharm to relieve symptoms and improve functioning: Carbidopa-levodopa standard treatment.
Can on/off phenomona with working/ not working of meds. Add catechol-O-methyltransferase
Adequate nutrition
Exercise

Dopaminergic agents and Parkinson’s
Carbidopa-levodopa.
Most effective drug.
Use with rasagiline.
May cause on/ off phenomena, dyskinesia, confusion, headache, hallucinatinos.

Dopamine agonists and Parkinson’s
Pramipexole and Ropinirole
May reduce risk for complications and alleviate symptoms.
Mono or dual theraoy with levodopa.
May cause N/V, dyskinesia, confusion.

MAO-B inhibitors and Parkinson’s
Rasagiline
Adjunct therapy
May cause serotonin syndrome, dyskniesia, arthralgia, ataxia

Amyotrophic lateral sclerosis (ALS): what and etiology
Disease of motor neurons causing asymmetric weakness, in upper or lower extremity. Less likely to present with resp weakness, dysarthria or dysphagia

Onset age: 50
Men more likely
Familial is 10% of cases
unknown

Average survival: 2-5 yrs

Symptoms and diagnostics ALS
Classified by number of upper and lower motor neurons in regions of brain
Progressive weakness over weeks/ months
Sensation intact
Muscle atrophy
Small muscle fasciculations
Hyperreflexia
Spasticity

Serum CK elevated
EMG: denervation
Muscle biopsy: atrophic muscle fibers
MRI: no abnormality

Management of ALS
Supportive and palliative:

Immobilty
Altered resp function: ventilation/ suction
Dysphagia/ poor nutrition
pain: pain management
Anxiety
Meds: riluzole. Can extend life by months but not cure.

Low back pain – major syndromes

Back strain
Disk herniation
Osteoarthritis/ disk degenration; osteophyte (bone spur)
Spinal stenosis: narrowing spinal foramen leading to spinal nerve entrapment

Specific findings for back pain

numbness
saddle anesthesia (CA, mass)
bowel, bladder dysfunction (emergency surgery)- pain worse at rest (CA, tumor, infection)
Discitis, epidural abcess (IV drug use)
Decreased rom
Radiculopathy (pain down leg), not with OA
Crossover straight leg test: herniated disk
back, buttock, leg pain when ambulating (neurogenic claudication with spinal stenosis). Also positive straight leg raise test with spinal stenosis

xr anteroposterior, to rule out scoliosis, bone spur
MRI for soft tissue structure, bulging disk
CT for bony imaging

Transient Ischemic Attack (TIA): what, etiology
Rapid onset of neurological deficit caused by focal brain, spinal cord, or retinal ischemia, resolves in 24hours.

atherosclerotic disease
cardiac emboli, from afib, mi, valvular disease
vasculitis, from lupus
hematologic causes (sickle cell, oral contraceptive)
high risk: older than 45, hx of thrombolytic event, history of spontaneous abortion, autoimmune, family hx
intracranial causes (brain tumor, seizures)
cocaine abuse
migraines

TIA risk factors
Important risk factor for stroke, especially in first week after

Risk factors for TIA:

HTN
Cardiac disease (afib)
smoking
obesity
hyperlipidemia
elderly
DM
alcohol, recr drugs

TIA symptoms
Carotid artery syndrome:

hemianopia, ipsilateral blindness
visual field cut
parasteshia/ weakness of contralateral arm/ leg/ face
dysarthria, aphasia
confusion
carotid bruit

Vertebrobasilar artery syndrome:

bilateral visual disturbances
vertigo and ataxia
N/V
drop attacks

TIA diagnostics

Lab: CBC, incl PT, PTT/INR, electrolyres, lipid profile
CT: may reveal ischemia or infarct
MRI: more sensitive than CT. Preferred for vertebrobasilar TIA
duplex US: to identify carotid stenosis
CT angio: to evaluate neck/ brain vessels (normal renal function required)
MR angio: can assess vessels. Good replacement for CTA.
echo or holter for cardiac concern/ assessment
TEE to assess aortic arch, left atrium, patent foramen ovale
cerebral angio if candidate for carotid endarterectomy

TIA management

Address underlying risk factors (HTN, DM, hyperlipid, smoking, obesity)
Carotid TIA: surgery if more than 80% occluded. No surgery if less than 50% (cand do stent then).
anticoagulation: heparin – warfarin. Though newer agents (Eloquis). PTT 1.5 – 2.5 x patient’s baseline.
Antiplatelet therapy: aspirin or plavix

Stroke: what, etiology
Rapid onset of neurological deficit lasting longer than 24hours. Leading cause of disability.
Ischemic or hemorrhagic. 80% ischemic.

HTN
Cardiac disease (afib)
smoking
obesity
hyperlipidemia (ischemic, low cholesterol hemorrhagic)
elderly
DM
alcohol, recr drugs
female on contraception and smoking

Education on stroke – five “suddens”
Sudden:
weakness
speech difficulty
visual loss
dizziness
severe headache

ischemic stroke: what, etiology
Thrombus in blood vessel in head or neck

Predisposing:

atherosclerosis/ hyperlipidemia
HTN
DM
hypotension
smoking
trauma
afib, endocarditis, mitral stenosis (embolism)

Ischemic stroke symptoms, based on location
Middle cerebral artery:

Hemiplegia (upper and face mostly), hemianesthesia, heminopia
aphasia
neglect

Anterior cerebral artery:

hemiplegia (lower mostly), primitive reflexes, confusion, behavioral changes if bilateral anterior

Vertebral and basilar arteries:

LOC
vertigo
dyshpagia, diplopia
ipsilateral CN findings
Contralateral sensory deficiency

Deep penetrating branches of major cerebral infarction (lacunar infarction):

associated with poorly controlled HTN and DM
contralateral pure motor and sensory deficits
ipsilateral ataxia
dysarthria

ischemic stroke diagnostics

CT head without contrast initially, preferable to MRI to rule out hemorrhage. Appears as area of density.
xr chest: possible cardiomegaly, neoplasm (metastasis brain suspicion)
Labs: CBC, Pt, PTT? INR, lipid profile, drug screen, alcohol level
ECG/ holter
MRI/ MRA (diffusion weighted more sensitive to detect cerebral ischemia)
CTA: vascular anatomy. Combine with CT perfusion which can show old infarct and salvageable areas.

Ischemic stroke treatment

appropriate time goals
BP control: Only treat if higher than 220 syst and 120 diast., aortic dissection, or receiving t-PA. For t-PA goal goal is less than 185 syst/ 110 diast, before t-PA and less than 180 syst/ 105 diast. after. Use repeat labetolol or nicardipine drip.
Anticoagulation: IV Heparin, bridge to Warfarin (PTT 1.5-2.5 baseline). But newer meds better: Dabigatran, Apixaban (Eliquis – for stroke prevention in afib), Rivaroxaban (stroke prevention afib). No routine labs necessary for those. Not for hemorrhage, cautino after GI bleed
Antiplatelet: Aspirin or Clopidogrel
Mannitol and hypertonic saline for cerebral edema, on second on third day. Monitor serum osmolality.
Corticosteroids to reduce cerebral edema from tumor burden.
surgery for high grade extracranial carotid artery disease (greater than 70%)

Time goals of stroke

ED eval within 10min
notify stroke team within 15min
CT scan within 25min
CT scan interpretation within 45min
Thrombolytic (if appropriate) within 60min
Transfer to bed within 3 hrs

t-PA

Pt needs to be in 3 – 4.5 hr window
Prior CT to assess for hemorrhage
need to have “last well known”
older than 18
ischemic stroke
neurochecks q15min for 2hrs, q30min for 6 hrs, q1h till 24hrs

Contraindications:

age greater than 80
previous hemorrhage
previous stroke within 3mo
major surgery last 14 days
Urinary/ GI hemorrhage within 24 days
seizure
PTT and PT elevated
oral anticoag/ heparin with elevated PTT/ PT
glucose less than 50/ greater than 400
SBP greater than 185 or DBP greater than 110
active internal bleeding last 22 days

Hemorrhagic stroke; what, etiology
Resulting from bleeding into subarachnoid space or brain parenchyma

SAH:
ruptured saccular aneurysm
arteriovenous malformation

ICH:
HTN

Predisposing:
HTN
anticoag/ thrombolytic
cocaine
alcohol
hematologic disorders

Symptoms SAH
Sudden severe headache “thunderclap headche” or “worst headache of my life”.
Graded Hunt and Hess):
1: asymptomatic
2: moderate/ severe ha, stiff neck, no focal signs other than CN palsy
3: drowsy, mild focal deficit
4: stupor, hemiparesis
5: deep coma, decerebration
Graded (Fisher):
1: no blood detected
2: diffuse/ vertical layers less than 1mm
3: localized clot/ vertical layer 1mm or more
4: intracerebral/ intraventricular clot with diffuse or nob SAH

Symptoms ICH

HTN
ha
vomiting (especially cerebral)

Basal ganglia:

eyes look to injury
decreased consciousness
contralateral hemiplegia

Thalamic:

looking at nose
pinpoint pupils
coma
flaccid quadriplegia

Cerebellar:

ipsilateral gaze paralysis
PERRLA
inability to stand/ walk
facial weakness
gait ataxia
vertigo
dysarthria

SAH diagnostics

CT head: ischemia or hemorrhage. Sensitive in first 3 days, after that consider LP. hard to see if smaller than 3mm.
LP is strong suspicion bit negative CT.
CSF: bloody ( 103 – 106 RBC), xantochromia (yellow, breakdown of blood)
CTA, prior to clot removal

ICH diagnostics

CT without contrast, to confirm bleed and determine size/ site. May reveal structural abnormalities.
Cerebral angio: determine source as aneurysm or an AVM.
MRI/ MRA: structural abnormalities
CBC, PT/ PTT, electrolytes, liver enzymes, kidney function

SAH management

ABC’s
may place external ventricular drain if hydrocephelus
bedrest strict
cardiac monitoring
treat ha, no NSAIDS (bleeding risk)
no straining/ exertion
stool softener
seizure prophylaxis (Phenytoine or Levetiracetam)
maintain SBP less than 160, may use nicardipine drip, labetolol push, hydralazine of brady
cerebral edema: mannitol or hypertonic saline.
surgical cliiping or coil asap
treat cerebral vasospasm
rebleeding: between day 2 – 19. Repeat CT.
cerebral salt wasting: hyponatremia. Crystalloid fluid replacement when euvolemia: 3% saline for hyponatremia
manage fever

ICH management

ABC, intubate/ give O2
Control HTN. SBP: 140 – 150. Nicardipine, labetolol
CPP: keep at 50 – 70
pressors if SBP less than 90: Dopamine, epi, levo
maintain ICP less than 20
mannitol for cerebral edema. For 5 days or less. check serum osmolality. Or 3% saline.
ventricular drain for hydrocephalus
keep euvolemia
seizure precautions (phenytoine, levetiracetam)
control fever
surgery if hemorrhage greater than 3cm

cerebral vasospasm

cerebral vasospasms: between day 7 – 10 after aneurysm lasting till day 21
symptoms: confusion, ams, neuro deficits, ha, increased icp. May cause infarction.
treat: calcium channel blocker: nimodipine. Symptomatic: tripe H. Hypervolemia, hypertension, hemodilution.

Meningitis, what and etiology
inflammation of arachnoid, dura mater, pia mater or spinal cord due to viral, bacterial, or fungal infection

predisposing: sinusitis, otitis, pneumonia, trauma, congenital malformation

Bacterial meningitis
Bacterial:

may be fatal in hours
exudate in subarachnoid space, thus thickened CSF and decreased flow

Most commonly caused by:

streptococcus pneumoniae (infants)
neisseria meningitidis (school, college, spread of drainage/ blood)
haemophilus influenzae (daycare children – vaccine)
Escherichia coli/ emterobacter/ klebsiella (infants, elderly, immunocompromised)
Atypical: mycobacterium, listeria

viral meningitis, what and etiology
Pia and arachnoid space filled with lymphocytes but not with exudate. benign and self-limited. In late summer/ early fall.
Transmission via cough, saliva, fecal matter

Caused by:
enterovirus, mumps, varicella, herpes, rubella, cmv, epstein barr, HIV

Fungal meningitis, what and etiology
Most common in immunocompromised

Causes:
candida
cryptococcus
histoplasma
aspergillus

Meningitis findings and diagnostics

severe ha
stiff neck/ nuchal rigidity
phtophobia
fever
ams
cranial nerve palsy
seizures
kernig’s sign: flex at knee, then hip, and extend knee. Causes pain and spasm of hamstring muscles
brudzinski’s sign: flex head and neck to chest. Causes legs to flex at hips
n/v
purpura/ petechiae on trunk and le
exaggerated deep tendon reflexes
LP
CT before LP, for ams or focal neuro signs or for CSF bacterial meningitis signs but no organism
bld culture, sputum cult, cbc, bmp
antigen tests and HIV testing

LP in bacterial versus viral meningitis
Bacterial:

Appearance: cloudy
Opening pressure: elevated (more than 180)
Cells: increased WBC’s (100-5000, polynuclear)
Protein: increased (100-500)
Glucose: decreased (5-40)
Culture: bacteria present

Viral:

Appearance: clear
Opening pressure: normal (less than 180)
Cells: increased WBC’s (100-5000, mononuclear)
Protein: normal or slightly increased (less than 200)
Glucose: normal (greater than 45)
Culture: no bacteria

Meningitis management
AB’s:

2 -50 yrs: vancomycin plus ceftriaxone
older than 50 yrs: vancomycin, plus ampicillin, plus ceftriaxone
Meningococcal meningitis (college): penicillin or ceftriaxone if pcn allergy
H.influenzae: ampicillin or ceftriaxone
tuberculosis: isoniazid plus pyridoxine, rifampin
s. pneumoniae (infants): add dexamethasone
no hypotonic fluids
amphotericin B for fungal meningitis

Cerebral abscess, what and etiology
Infected space occupying lesion, from bacterial or fungal source (sinusitis, lung infection, skin infection, trauma)

Cerebral abscess findings, diagnostics

ill appearing/ lethargic
signs of increased ICP (n/v, confusion/ ams)
stage 1: ha, chills, fever, confusion, speech disorder
stage 2 (expanding cerebral mass): signs and symptoms of brain tumor: ha, confusion, drowsy, stupor
Lab: increased WBC and ESR
LP (CT prior to LP): elevated opening pressure, mildly elevated protein
CT
MRI: reveals necrosis vs edema

Cerebral abscess treatment

AB based on microbiology
surgery and debridement when abscess is greater than 2.5cm

Encephalitis, what and etiology
Acute inflammation of the brain

most commonly caused by herpes simplex virus
tick infestation
west nile virus
toxoplasmosis (AIDS pt’s)
CMV
rabies

Encephalitis findings and diagnostics

lethargy
unstable vitals
nystagmus, photophobia
n/v
nuchal rigidity
ha
pos babinski
Lab: CBC, liver, BMP, fluid cultures
LP: elevated WBC, normal or slightly elevated protein, normal or slightly elevated glucose
EEG
IgM meausring in serum and CSF, pos in CSF
CT
MRI

Encephalitis treatment

IV fluids
resp and circulatory support
anticonvulsants
monitor for SIADH
for HSV: acyclovir
report to CDC

encephalopathy, what and etiology
Dysfunction of brain caused by disease (process)

Hepatic, hypertensive, metabolic, hypercapnic cause
Thiamine deficiency (wernicke)

encephalopathy, findings and diagnostics

ha
ams
confusion
ammonia may be elevated
CSF analysis
EEG
MRI

encephalopathy treatment

ABC’s
correction underlying cause
anticonvulsant therapy

Seizure/ epilepsy, what and etiology
Seizure: abnormal neuronal discharge within brain
Epilepsy: recurrent, unprovoked seizures

unknown cause
metabolic disorders (acidosis, hypoglycemia, hypoxia, alcohol withdrawal)
CNS infection
tumor
noncompliance with epilepsy meds

Focal seizures
one cerebral hemipshere:

without dyscognitive features (aware). May have sensory changes, autonoic (sweating, flushing), sppech arrest, aura, psychic symptoms
with dyscognitive features (unaware). most common seizure. Simple partial seizure followed by loss of awareness. Automatisms. Begins with aura often.

Generalized seizures

typical absence seizures: sudden loss of consciousness (5-30sec), mild clonic/ tonic movements, several times/ day
atypical absence seizures: longer loss of consciousness, obvious motor signs
generalized tonic-clonic seizures: discharge throughout cerebral cortex. Abrupt start with outcry, loss of consciousness/ falling, resp arrest, tonic and clonic movement, urinary incont, 2-5min, postictal state

status epilepticus
a prolonged seizure (longer than 5min) or situation when a person suffers two or more convulsive seizures without regaining full consciousness

Requires aggressive tx

medical emergency

Seizure diagnosis
-EEG/ 24 hrs: focal abnormalities: partial seizure, generalized abnormalities: generalized seizures

CT head
LP if CT or MRI did not show anything
CBC, BMP
ua: drug screen
elevated prolactin

Seizure management

supportive
open airway, left side laying, do not force anything in mouth (airblade)
IV with NS
ECG, bp
benzodiazepine first treatment: ativan, diazepam, midazolam (may give midazolam IM if no IV present)
Phenytoin, loading dose 20mg/kg
Fosphenytoin, can be given faster than phenytoin
if still seizing after 1hr: propofol
taper drugs, never stop abruptly

Dermatitis Medicamentosa (Drug Eruptions)
Abrupt, widespread, and symmetric eruption. If exposed before, it may take only very little to elicit response again.

Predisposing factors for dermatitis medicamentosa – classification
Type 1: immediate-type immunologic reaction: by IgE. Looks like: urticaria and angioedema of skin and mucosa, and fall in bp (anaphylactic shock)

Type 2: cytotoxic reaction. drug causes lysis of cells or produce antibodies.

Type 3: serum sickness, drug-indiced vasculitis. Looks like: vasculitis, urticaria-like lesion, arthritis, nephritis, alveolitis, hemolytic anemia, thrombocytopenia

type 4: morbiliform. Cell-mediated. Drug erruption with eosinophilia and systemic syndromes (DRESS). Allergic reaction causing systemic reaction, presenting as hepatitis, pneumonia, lymphadenopathy, nephritis. May last 2-6wks after start med. Often: anti-epileptocs, B-blocker, allopurinol.

General points for dermatitis medicamentosa

Amoxicilllin/ ampicillin/ penicillin: common cause urticaria and maculopapular allergic skin reaction
Cephalosporin can cause reactions to pcn allergic patients. Third generation less likely than first generation.
Red man syndrome caused by vancomycin. Responds to slowing of rate.
ACE-inhibitors associated with chronic cough and angioedema
B-blocker can precipitate asthma.
Anticonvulsants and sulfonamides most common cause of toxic epidermal necrolysis and Stevens-Johnson syndrome.
May give Prednisone and hydrocortisone before IV contrast is suspected allergy

Dermatitis medicamentosa: symptoms and diagnostics

abrupt onset
bright erythema
facial edema/ involvement
swelling tongue
itching
fever/ chills
symmetric distribution of skin reaction
arthralgia
possible: sob, wheezing, hypotension
if urticaria and angioedema present, then mast cell degranulation, so repeat reaction is likely.
maculopapular rash, most often on trunk
ecxematoid rash
photodermatitis
may have: hemolytic anemia, liver/ kidney dysfunction, serum sickness (rash, fever, malaise)
clinical diagnosis
blood work no value
eosinophil count greater than 1000
skin biopsy
challenge dosing – if anaphylactic reaction not likely
serum renal/ liver if indicated

Dermatitis medicamentosa, management

Withdraw drug – may be only thing necessary
Epi0.5-1ml IV or SQ relief from urticaria and angioedema. Repeat after 20min up to three doses
Oral/ IV antihistamine: benadryl or Ranitidine
Severe cases: Prednisone, taper slowly
Bronchodilators for wheezing

Cellulitis: what
Infection of dermis and subcutaneous tissue.
Caused by gram Pos cocci and staph. aureus (for dm) as well as gram neg. E.coli. Fungi for neutropenic patients. H. influenza for facial and upper extremities.

Cellulitis, general comments

break in skin precedes cellulitis,
Risk factors: trauma, underlying skin lesion, diabetes, pedal edema, venous/ lymphatic compromise, IV drug use
may be next to necrosis or abscess
often lower extremities
complicated by DVT

Cellulitis findings

tenderness, pain, swelling, erythema, warmth
rapid increase intensity and spread
fever, chills, malaise
sepsis possible
erythema with indistinct margins; warmth and tenderness
enalargement and tenderness of regional lymphnodes
red streaks from site (lymphatic spread: lymphangitis)
erythema and tenderness few cm from site
Lymphnode enlargement and lymphangitis: cellulitis.
Blood culture and wound culture
Rule out: DVT and necrotizing fasciitis, which should be suspected in very sick pt with bullae, crepitus, anesthesia of involved skin, skin necrosis, rhabdo, DIC

Cellulitis treatment

AB: cover streptococci and staphylococci, with penicillin, Cephalexin, Dicloxacillin. If allergy to pcn: erythromycin or clindamycin.
Inpt AB: nafcillin, Cefazolin, Vanco for MRSA suspicion,
Hospitalize very sick or immunocompromised and treat with vanc.
Immobilization and elevation of limb
moist heat
low dose, long-term pcn for recurrent cellulitis

Herpes Zoster (shingles): what, etiology
Reactivation of latent varicella-zoster virus, characterized by unilateral pain present 48hrs before rash. Rash: single dermatome: vesicular or bullous erruption

older than 50
impaired immune system, lymphoma, fatigue
can have postherpic pain for up to 1mo

Herpes Zoster findings and diagnostics

Prodormal pain symptoms (sharp), burning, itching in affected spot
malaise, low grade fever, headache
allodynia
lymphadenopathy, 1 -2 days prior
grouped vesicles on erythematous tender base along nerve group
papules appear within 24hrs and progress to vesicles and bullae within 48hrs, then pustules with cloudy fluid. Crusts for 7-10days.
ECG during prodormal: rule out cardiac disease
VZV antigen detection
positive Tzanck test
viral culture

Herpes Zoster management

consult ophthalmology for HZ on tip of nose
antiviral therapy for 50-50-50: 50hrs or less since onset, 50yrs or older, more than 50 lesions
Acyclovir 5/ day. Adjust for renal impairment.
pain control with opioids
Moist dressing: water, saline 15min qid
Hydroxizine for pruritis
postherpetic neuralgia pain: Lidocaine patch, Pregabalin
pregnant women should avoid

Skin cancer: 2 main types, etiology
Basal cell carcinoma: most common type.

Fair skinned people.
Waxy, pearly appearance.
Slowly grows 1-2cm over years.
Limited capacity to metastasize.
sun exposure before age 14
rare in brown/ black people
face/ neck

Squamous cell carcinoma.

Non-healing ulcer/ wart-like.
From actinic/ solar keratosis.
Can metastasize (especially on lip, oral cavity, tongue, and genitals)
Result of exogenous carcinogens.
more male
smokers: lip
females: legs

BCC and SCC findings and diagnostics
BCC:

nodule or ulcerative tumor: small, pearly, waxy. Translucent borders, elevated and shiny fine telangiectasis
superficial BCC: erythematous scaly macule with threadlike border

SCC:

firm, skin to red- colored nodule on damaged skin
central ulceration
scaling and crusting
on head/ neck
Biopsy, shaved (for raised lesions), or punch biopsy (small distinct bordered lesion), incisional biopsy (large lesion)
Curettage and electrodesiccation in three cycles for BCC lesions smaller than 1cm = gold standard

Skin cancer: BCC and SCC, management

consult dermatologist
cryosurgery
microscopically remove, to ensure clear borders
radiotherapy only for very large
prophylaxis therapy: 5- Fluorouacil or Imiquimod
sunscreen

Melanoma: what, etiology
Tumor with dark pigmentation, flat or raised, irregular borders, greater than 6mm

Leading cause of death from skin disease
avoid blistering sun radiation
age: between 30 and 50
fair skin, blue eyes, blond
twice risk if sunburned young
twice the risk with many nevi
head/ neck/ trunk for males, lower extremities for females

Melanoma: findings and diagnostics

change in pigmented lesion:
bleeding/ ulceration bad sign
scaling
texture change, irregular border
bigger than 6mm
color change
itching

ABCDEE changes:
Assymetric shape
Border irregularity
Color change
Diameter greater than 6mm
Elevation
Enlargement/ increase in size

Surgical biopsy: full thickness total excisinoal biopsy. Do not shave, curette, or electrodesiccate melanoma

Melanoma staging
Clark staging:
Level 1: epidermis – in situ
Level 2: invasion of papillary dermis
Level 3: invasion of interface of papillary, reticular dermis
Level 4: invasion of reticular dermis
Level 5: invasion subcutaneous fat

Breslow staging:
Thin: less than 0.75m depth
Intermediate: 0.76 – 3.99mm depth
Thick: greater than 4mm depth

Melanoma Management

dermatologist
follow up q3-6mo
Based on stage:
Less than 1mm: wide excision 1mm. No lymphnode dissection
1-4mm thick: wide excision 2mm. Nodal biopsy recommended. Lymphatic mapping.
4mm thick: wide excision more than 4mm
Adjuvant therapy: hem/ onc. Alpha-interferon

Types of wounds
Acute:
Acute surgical: clean/ contaminated
Traumatic wound: clean/ contaminated

Chronic:
Arterial: ischemia from arterial occlusive disease
Venous: venous return disorder
Diabetic: from hyperglycemia and per neuropathy
Pressure: prolonged pressure

Factors that delay wound healing

pressure
decreased tissue perfusion/ oxygenation
incontinence
infection
dm
poor nutrition
steroids
immunusuppression
aging

Wound findings, specifics

Pain
Arterial: claudication
Venous: lower extremities heavy and sore
Neuropathy: numbness, tingling
Arterial, venous, diabetic: poor healing

Wound depth, levels

Superficial
Partial thickness: through epidermis, partially into dermis
Full thickness: through epidermis and dermis and some subcut layer. Muscle/ bone may be involved.
Undermining and tunneling

Wound colors
Red: healthy
Yellow: debridement/ cleaning needed
Black: necrotic

Findings arterial and diabetic ulcers

On toes and below ankles (arterial)
plantar surfaces of feet (diabetic)
diminished pulse
shiny, cool le skin
no leg hair
thick toe nails
deep ulcer with smooth wound margins, small amount of drainage/ necrosis

Findings venous ulcers

lower legs, above ankle
varicoses present
edema of le
warm le
superficial, granulating ulcer with irregular margins, with heavy drainage

Findings pressure ulcer

On bony prominences
Stage 1: skin intact, but skin non blanchable
Stage 2: partial thickness loss
Stage 3: full thickness loss, deep craterlike
Stage 4: full thickness and extensive destruction with tissue necrosis

Diminished arterial and venous flow diagnostics

Doppler, reduced PVR waveforms
Digital plethysmography: systolic toe pressure. Normal is 80-90%
Transcutanous oxygen measurements: higher than 30, wound will heal. Lower than 20, will not heal
Venous doppler ultrasound: may show clots or incompetent valves

Refer to vascular surgeon when
Urgent:

gangrene
tendon/ bone visible
cellulitis
severe infection
ankle-brachial index less than 0.5

Semi-urgent:

TCPO2 measurement higher than 30
weak/ absent pulse
ankle/brachial index 0.5-0.8

Routine:
-ankle/ brachial 0.8

Management arterial ulcer

wet to moist dressing
collagenese, apply to ulcer directly
no surgery
calcium alginates
no occlusive dressings
analgesics
treat underlying condition

Management venous ulcer

Elevate leg
nonadherent dressing under compression
Compression therapy
sharp debridement if cellulitis/ infection
collagenese
treat underlying condition
AB’s: cephalexin or erythromycin if allergic to pcn. Or cefazolin iv
Linezolid or Vanco if MRSA suspicion
Analgesics

Management diabetic ulcer

Increase insulin or oral hypoglycemic
no weight bearing
incision/ drainage as indicated
PRN topical antimicrobial
non-occlusive/ non adherent dressing
enzymatic debridement: collagenese
AB’s:
mild: cephalexin, amoxicillin, for MRSA: doxycillin or bactrim
moderate: levofloxacin and severe MRSA: vanco.
severe: vanco
analgesic
wet to moist dressing qid

Management of pressure ulcers

positioning
support surfaces
skin barrier products – hydrocolloids
debridement
cleansing: NS. Irrigation for dirty.
keep ulcer moist
topical AB’s PRN
diet: increased protein/ high caloric diet
analgesics PRN

Types of burns

Thermal; flames, hot objects. Most common type of burn
Chemical; necrotizing agents
electrical; causes damage to nerves and tissues
inhalation injury; smoke/ hot air. Incl Carbon monoxide
cold thermal; frostbite

Categories of burns

First: painful, dry, red, no blisters, epidermis only
Second: severly painful, moist blisters, beyond epidermis, infection barrier destroyed
Third: not painful/ nerve destroyed, leathery, black/white, pearly, from epidermis to dermis to underlying tissue/ fat/ muscle/ bone

Extent of burns measurement
Rule of nines:

each arm: 9%
each leg: 18%
thorax: 18% front, 18% back
head: genitals 9%
perineum/ genitals: 1%

Fluid resuscitation in burns

2-4ml/kg x total body surface area in first 24/hrs
Asap. Even before hospital.
Half of all fluids within first 8 hrs.
Give crystalloids (NS/ LR), no colloids (albumin, plasma)
Urine output should be 30-50ml/hr
Monitor for hyperkalemia first 24-48 hrs, after that hypokalemia.

General burn management rules

rinse chemical injuries in water, no other products
wrap area in clean, dry towel (not wet, to keep body temp)
dressing before treatment: wrap in ns and sterile towels
maintain normothermia (warming blankets, etc)
analgesics (morphine), only iv
topical ab options: silvadene, sulfamylon, collagenase
intubate for one of these: burn to face, singed nares/ eyebrows, dark soot from nares, hoarseness, drooling, difficulty swallowing. AND bronchoscopic laryngeal edema

Transport to burn center for

2nd degree, more than 10% TBSA
3rd degree
electrical burn
chemical burn
inhalation injury
burned children
burn injury is big risk for mortality

carbonmonoxide poisoning

CO replaces Hgb
Cause: home furnace/ gas and car exhaust
signs: ha, dyspnea, confusion, n/v, tachy, seizures, coma, death
Give 100% O2
potential hyperbaric oxygen chamber

Laceration treatment
Cleanse (NS)
Debridement (for contaminated wound) (potential excision)
Control of hemorrhage – pressure, elevation, ligation, tourniquet
Closure (do not close contaminated wound)

Suturing

not too tight
choose smallest suture size
remove after 5-7 days or 10 days on trunk and extremities

Nerve block for laceration

1% lidocaine with epinephrine, do not exceed 7mg/kg or 4mg/kg without epi
or Procaine
choose small needle (30gauge)

Aneurysm: what and types
Dilation of arterial wall because of abnormal weakening, often from sudden increase in bp

Types:
Berry (saccular)

congenital aneurysm of cerebral vessel.
Common in adults
Asymptomatic

Fusiform

tapered at both ends
common in vertebrobasilar system

Mycotic

bacterial cause/ infection

Traumatic

Locations of intracranial aneurysms and effect of rupture

Most in carotid system: anterior communicating artery, posterior communicating artery, middle cerebral artery
some in posterior circulation: basilar and vertebral

Rupture result:

subarachnoid hemorrhage
intraventricular hemorrhage
intracerebral hemorrhage
subdural hematoma

Risk factors for intracranial aneurysm

hereditary/ familial
smoking
women above 50 (postmenopausal)
alcohol use
7mm risk for rupture

Intracranial symptoms and diagnostics

asymptomatic until rupture, then SAH
warning leaks (small amount of blood) hours prior to rupture: headache, neck stiffness, nausea
eye hemorrhage on ophthalmologic exam
aneurysm with mass effect (bigger than 25mm): headache, palsy of CN 3 (pupils), brain stem dysfunction
CT . Very sensitive within 24hrs. Less after 5-7 days.
CTA
MRI best for detecting thrombus in aneurysmal sac
CTA, help in therapeutic decision making
WBC and ESR up in ruptured aneurysm

Intracranial aneurysm management

Surgery: consider for warning symptoms (headache, neuro signs) and salso consider comorbodities.
early surgery (within 72hrs of bleed) is desirable
clipping, wrapping, embolization
or manage nonsurgically as SAH

Aneurysm complications
Vasospasm

3 or 4 weeks after tx
give calcium channel blockers (nimodipine)

Rebleeding

risk within 2-24hrs of 1st hemorrhage
prevent htn
give antifibrinolytic agents: transexamic acid. If given in first 2 wks after bleed reduces risk for rebleed.

Hydrocephalus

may require shunt placement, ext ventricular drain, lumbar drain

Seizures

Increased intracranial pressure

arteriovenous malformation (AVM)
a vascular malformation that is a tangle of abnormal blood vessels connecting arteries and veins in the brain; has increased risk of bleeding and decreases normal oxygen flow to local tissues (no capillary bed for gas exchange)

Treat with: embolization, surgical excision

Dural arteriovenous fistula
Fistula between artery and vein in dura matter. Signs: tinnitus, headache

Treat with: embolization, surgical excision

Chiari malformation
part of cerbellum herniates down through foramen magnum

Treat: surgery

Hydrocephalus: what, etiology
Excessive amount of CSF in cerebral ventricles. Can be acute or normopressure

oversecretion CSF
obstruction of CSF (tumor/ lesion)
impaired absorption
head injury

Hydrocephalus classification
Communicating:

from impaired absorption or overproduction
after aneurysmal rupture

Noncommunicating:

obstruction in ventricle, thus no communication with subarachnoid space
from lesions or tumors

hydrocephalus signs
Acute:

papilledema
ha
n/v
gait change
upward gaze

Normopressure:
Triad: dementia, gait disturbance, urinary incontinence

hydrocephalus management
Acute: ext ventricular drain

Chronic: ventricular shunt

Ventriculostomy- surgical

Brain tumor
Primary: originating in brain
Secondary: metastases

Most common: gliobastoma multiforme

Most common brain tumors
Gliobastoma multiforme

nonspecific symptoms, focal deficits as tumor grows
rapid course, poor prognosis

Astrocytoma

longer course
variable prognosis
might do total surgical removal

Meningioma

compresses instead of invading neural structure
common with advancing age
surgical treatment, potentially with radiation

Brain tumor signs and diagnostics

progressive neuro deficit
ha
seizures
MRI, procedure of choice
CT to also look at other body parts
EEG for seizures
CT angio to asses vessels
barin biopsy for definite diagnosis
metastatic work-up necessary

Brain tumor management

oncologist
chemo
radiation
corticosteroids: dexamethasone (start H2-blockers simultaneously)
mannitol for sever cerebral edema
anticonvulsants for repeated seizures

Guillain-Barre syndrome, what, etiology, prognosis
Acute, rapidly progressive inflammatory demyelinating radiculoneuropathy: motor greater than sensory resulting in increased msucular weakness, mild sensory loss, auronomic dysfunction. Often following an infection. Cause: myelin destruction or complexes attacking axons and nerve conduction
Max deficit by week 4.

possible autoimmune
antecedent infection
incidence increases with age
more men

Improvement may take months. May keep mild disability.

Guillan Barre signs and diagnostics

symmetric, rapidly progressive muscle weakness and parasthesia, beginning in legs and moving up. Can lead to total paralysis/ death
reduced deep tendon reflexes
more weakness than sensory loss
may have hyperesthesia
dysphagia
respiratory paralysis
autonomic dysfunction: tachycardia, bp fluctuations, cardiac arrythmia
CSF: elevated fluid protein, but may be only after couple of weeks
leukocytosis
may require lp
will find: demyelatino of peripheral nerves or inflammation of myelin sheath
antibodies: GM1 or amti-GQ1b
slowed conduction on electromyography

Guillan barre management

no known cure
consult neuro
icu
intubation
immunomodulating treatment and plasmapharesis (first line!)
no corticosteroids
prevent thromboembolic events (hep sq q8h)
pain control (especially during reinnervation)
GI prophylaxis – H2 blocker
protect skin
rom
nutrition management
rehab

Myastenia Gravis (MG): what and etiology
Disorder of neuromuscular junction resulting in pure motor syndrome: fluctuating muscle weakness most notable after prolonged muscle use
Cause: autoimmune attack on acetylcholine receptor at the postsynaptic membrane.
Mild and intermittent or sudden severe onset

more women early adulthood, equal later in life

Myastenia Gravis symptoms and diagnostics

Ptosis
Diplopia
facial weakness
fatigue from chewing
neck weakness
more upper than lower limb weakness
resp weakness
may cause severe quadriparesis
Antibody testing: ACHR and MUSK pos
increased jitter on electromyography
Edrophonium test (Tensilon): in MG will have brief improvement when given Edrophonium. No improvement if cholinergic crisis
MRI/ C
Thyroid function tests: may have thyroid disease
Vit B 12 low, pernicious anemia
ANA, RA factor pos
normal LP

Myastenic crisis
Defined by resp failure, requiring mechanical ventilation, following increasing muscle weakness and diplopia. More likely in MUSK positive.
This often follows an infection, stress, steroid change, drug exposure

myastenia gravis treatment

neuro
-Symptom mamagement with:
Pyrodostigmine bromide – slows down degradation. Monitor for cholinergic adverse effect: n/v, diarrhea, bronchial secretions, cramps.
Immunomodulating therapy: Prednisone, taper to low maintenance. Azathriopine.
Management of impending crisis: intubate.
And give rapid immunomodulating therapy: IVIG.
Can also do plasmapharesis. Removes antibodies.

GCS measures
The GCS measures the following functions:

Eye Opening (E)

4 = spontaneous

3 = to sound

2 = to pressure

1 = none

NT = not testable

Verbal Response (V)

5 = orientated

4 = confused

3 = words, but not coherent

2 = sounds, but no words

1 = none

NT = not testable

Motor Response (M)

6 = obeys command

5 = localizing

4 = normal flexion

3 = abnormal flexion

2 = extension

1 = none

NT = not testable

GCS outcomes
Severe: GCS 8 or less

Moderate: GCS 9-12

Mild: GCS 13-15

Ectopic pregnancy: what, etiology
Implantation of fertilized ovum in other place than endometrium, often fallopian tube

Could be caused by:
PID, especially gonorrhea and chlamydia
endometriosis
IUD
tubal tumors
On Clomid
smoking

Most common cause for maternal mortality

Ectopic pregnancy findings and diagnostics

missed period, then continued intermittent bleeding
sudden, sharp abdominal pain, diffuse pelvic pain, and radiation to shoulders/ neck
fainting, vertigo
n/v
right or left pelvic pain
hypovolemic shock signs
cullen sign
normal uterine size
adnexal mass
bimanual exam painful with cervical motion tenderness
unilateral rebound tenderness
Hgb and HCT low with leukocytosis
HCG greater than 1500 but lower than what it should be for gestational age
no intrauterine gestational sac
ultrasound

Ectopic pregnancy management

outpt lap: salpingectomy
outpt methotrexate therpay
central line if hemodynamically unstable
blood transfusions
Cefoxitin for empiric gram neg and pos coverage
pain control with percocet
biweekly HCG

Methotrextae therapy:

Criteria: less than 6 wks, tubal mass smaller than 3.5cm, no embryonic motion, no renal/ hepatic disease, hemodynamic stability
Pretreatment: transvaginal us, HCG level, liver and renal function labs, blood type, CBC, bone marrow tests
contraindictations: intrauterine pregnancy, immunodeficiency, methitrexate sensitivity, low blood counts, hemodynamically unstable, pulm disease, liver or renal failure, breastfeeding, tubal rupture
either single dose or multiple dose regimen

PID (salpingitis): what, etiology, cimplications
inflammation of upper female genital tract, by bacterial infection

very common
most common caused by: gonorrhea and chlamydia
Or: H ingluenzae and Gardnerella, streptococci, gram neg rods, mycoplasma hominis
trauma and surgery can also cause it
sexually active, multiple partners
reduced socioeconomic status
sexual exposure to urethritis
3 weeks after IUD placement
douching
during period
smoking/ substance abuse

May cause:

infertility
tubal pregnancy
tubo-ovarian abscess
recurrent PID
infectious perihepatitis (Fitz-Hugh and Curtis Syndrome)

PID/ salpingitis findings and diagnostics

purulent vaginal discharge
bleeding cervix
cervical motion tenderness (chandelier sign)
abd rebound tenderness
ruq abd pain (with Fitz-High and Curtis Syndrome)
assess last period
STI hx
contraception use
sexual hx
pregnancy test
drug allergy
CDC criteria

CDC PID/ salpingitis criteria
Needs to have one of these:

uterine/ adnexal tenderness
cervical motion tenderness
And potentially:
fever
purulent vaginal discharge
elevated ESR
gonorrhea or chlamydia
WBC up
Definite:
evidence from endometrial biopsy
tuboovarian abscess on US
lap.scopic abnormalities consistent with PID

PID/ salpingitis management

Early and aggressive tx of STIs will prevent PID
Admit for: surgical emergencies, coexisting pregnancy, failure to respond to tx
notify sexual partners
test for cure after 7days
rescreen for gonorrhea and chlamydia after 4-6 wks
remove IUD
test for HIV
no douching
no sex
bed-rest semi-fowlers
Tylenol

Inpatient:

Cefotetan or Cefoxitin
Doxycycline
Clindamycin or Metronidazole with Doxy for abscess
Or:
Clindamycin
Gentamicin
Continue till 24-48hrs after improvement

Outpt:

Ceftriaxone – single dose
Doxycycline
Metronidazole
Or:
Cefoxitin
Doxycycline with Metronidazole

Vaginitis – what
Most commonly: bacterial vaginosis, vulvovaginal candidiasis, trichomoniasis

Vaginitis, findings

vaginal discharge
vulvar itching/ irritation
vaginal odor
asymptomatic

On speculum exam:

Bacterial vaginosis: adherent, thin, milky foul/ fishy smelling discharge
Candidiasis: thick, clumpy, white cottage cheese discharge. Inflammation, erythema
Thrichomoniasis: frothy, gray/ yellow/ green discharge. Cervical petechiae: strawberry cervix.

Vaginitis, diagnostics
Bacterial vaginosis:
Amsel criteria:

vaginal PH greater than 4.5
clue cells on wet mount
whiff/ fishy odor test
milky- white discharge, adherent to vaginal wall

Candidiasis:
wet mount: pseudohyphae and or budding yeast

Thrichomoniasis:

wet mount: motile trichomonads seen
vaginal PH greater than 4.5
culture
nucleic acid amplification test

Vaginitis treatment

Enclose to partner and treat
no sex

Bacterial vaginosis:

Metronidazole PO or intravaginally
Tinidazole

Candidiasis:

Fluconazole PO
Butoconazole intravaginally

Thrichomoniasis:

Metronidazole

While pregnant: Metronidazole or Clindamycin

Chlamydia, what and etiology
Parasidic STI producing reproductive tract complications. Caused by: C. trachomatis. Transferred by body fluids

both sexes, younger than 25
annual screening for sexually active adolescents and not using contraceptives, pregnant, or abortion

May cause:
Women:

PID
ectopic pregnancy
infertility
late onset postpartum endometritis
Men:
Epididymitis
urethritis, conjuctivitis, arthritis, skin lesions
Newborn:
conjunctivitis
pneumonia

Chlamydia findings
Female:

asymptomatic
postcoital bleeding
lower abd pain
dysuria
painful sex
purulent discharge

Male:

asymptomatic
dysuria
penile discharge, thick
unilateral testicular pain/ swelling
Fever
abd pain: guarded and rebound
genitalia: edema, ulcerations, lesions, erythema
speculum: red vaginal walls, red cervix, purulent discharge, cervical lips eroded
bimanual exam: cervical motion tenderness (Chandelier sign), adnexal pain, uterine pain
male inspection: meatus edge red and swollen, unilateral testicular pain

Chlamydia diagnostics

Gold standard: McCoy cell culture (takes 2-6 days for results)
Non culture tests: not as sensitive but results available sooner
wet mount: polymorphonuclear cells
test for syphillis and gonorrhea
HIV testing
Hep B testing

Chlamydia management

Azithromcyin or Doxycycline
May give Erythromycin or Ofloxacin

Pregnant:

Azithromycin or Amoxicillin
Or Erythromcyin
treat partner and evaluate last sexual partners
test of cure after 3 wks
no sex
use condom
report to health department

Gonorrhea, what and etiology
Bacterial STI, can be symptomatic or asymptomatic. Most commonly in cervix for women. Caused by N. Gonorrhoeae, gram negative, from GI tract, oropharynx, anorectum. Incubation period: 3-7 days

more male to female exposure than other way around

Can cause:

PID
ectopic pregnancy
infertility
Perihepatits (Fitz-Hugh and Curtis syndrome)
Epididymitis

Gonorrhea findings
Female:

asymptomatic 80%
Early:
dysuria/ frequency
purulent discharge
labial pain/ swelling
lower abd pain
pharyngitis
Late:
fever
abnormal periods
n/v
joint pain/ swelling

Male:

asymptomatic usually
Early:
dysuria/ frequency
white discharge
pharyngitis
Late:
yellow/ green discharge
epididymitis
lower abd pain
fever
Abd pain: guarding, referred, rebound
Hyperperistalsis
Painful, enlarged Bartholin and Skene glands
urethral discharge
red vaginal wall
-purulent drainage from cervix
adnexal pain and masses
cervical motion tenderness
red and swollen penile shaft

Gonorrhea diagnostics

Corner stone diagnosis: perform throat and endocervical culture for oral/ vaginal sex
rectal exam for anal sex
check for Chlamydia and syphilis and HIV
leukocytosis
ESR up
males: one hour after voiding

Gonorrhea management

Ceftriaxone single
Azithromycin or Doxy 7 days

Pregnant:

Azithromycin
Tell sexual partners and treat, and screen also for chlamydia
no sex
test for cure after 3mo
hospitalize for disseminated gonococcal infection
report to health department

Herpes simplex virus: what and etiology
Recurrent, incurable viral infection of genital or orofacial skin, with fluid containing eruptions on red base. two strains: HSV-1 and HSV-2.

HSV-1:

herpes labilialis (cold sores) and herpes keratitis
gingivostamitits: children and adults
healing of lesions after 3 wks
more common

HSV-2:

mostly genital
later in life, more severe and recurrent
lesions heal in 2-3 wks
Transmitted by vaginal, anal, oral contact/ very close physical contact
improper use of condom

genital herpes findings

Flulike symptoms
pharyngitis
itching, pain
urinary retention and dysuria
le weakness
hyperparesthesia
small, multiple painful vesicles over external genitalia
painful ulcerating papules
white necrosis on cervix
inguinal lymphadenopathy
extragenital cutaneous lesions on hips/ buttocks

Recurrent:

precipitated by trauma, period, stress, illness, fever, sun
local burning, itching, tingling
lesions in 3 days, resolve in 7 days

genital herpes diagnostics

Tzanck smear: immediate results and sensitive
collect specimen from vesicular lesion
HSV culture (test of choice). Results in 7 days
Western blot also accurate

Herpes management

No cure

First episode:

Acyclovir
Pregnant:
Doxycycline

Recurrent:

Acyclovir
suppressive tx if more than 6/ year

Teaching on sexual transmission

Human Papillomavirus (HPV), what and etiology
Infection at basal cell layer that causes genital warts, cervical abnormalities, and cancer
Low risk for ca: HPV 6 and 11 and low grade cervical changes
High risk for ca: HPV 16 and 18

Incubation: week to months for warts, years for cancer

Most common STD

HPV findings and diagnostics

no findings often
genital warts: cauliflower like, smooth/ flat papules, warts in areas of coital friction
visual inspection of genital warts
biopsy for: uncertain diagnosis, immunocompromised, worsening lesions despite tx, persistent ulceration

HPV management

Pap smear for all sexually active women
tx will treat infectivity but not cure
sinecatechins ointment or imiquimod on warts until gone
Cryotherapy
Partner exam not necessary
all women age 9-26 should get vaccine

Syphilis, what and etiology
Systemic STI with 4 stages: primary, secondary, latent, tertiary. caused by treponema pallidum. Incubation period: 21 days. Infection at site of inoculation: small sore.

Syphilis findings
Primary:

Chancre (painless, indurated ulcer). heals in 1-5 days.
regional lymphadenopathy

Secondary:

Flulike symptoms
maculopapular rash on palms and soles of feet 2-6 wks after infection
patchy alopecia
wartlike lesions in mouth, throat, cervix
resolves in 12 wks

Latent:

infectious for one year then noninfectious
blood test still pos for T pallidum

Tertiary:

gummatous syphilis (soft granulomatous tumor)
cardiovascular syphilis
neurosyphilis

Syphilis diagnostics

Dark field microscopic exam and direct fluorescent antibody test
VDRL and RPR test, 1 – 2 wks till results
Treponemal specific test

Syphilis management
Early, primary, secondary, latent:

benzathine penicillin

Tertiary, exl neurosyphilis:

benzathine penicillin

Neurosyphilis:

aqueous crystalline penicillin or procane penicillin
If allergic to pcn. Desensitize first.
Follow up after 3 and 6mo
Treat sexual partners presumptively
Report to health department

Acetaminophen toxicity findings and diagnostics

N/V at 24-48 hrs
RUQ pain
Hypotension
Hypothermia
Hepatotoxicity; jaundice, prolonged bleeding time, hepatic encephalopathy
Draw labs after 4 hrs of ingestion
Toxicity/ liver injury at more than 7.5gr, but at lower doses for preexisting liver injury
monitor q24hrs: ALT, AST, BUN, creat, PT, bili, metabolic acidosis, lactic, alk phos, phosphate, PH

Acetaminophen toxicity management

Activated charchoal, within 4 hrs after ingestion (10grams per 1 gr acetaminophen)
Remove charcoal with gastric lavage before Acetylcysteine
Acetylcysteine, within 8-10hrs of ingestion. PO or IV

Alcohol toxicity findings and diagnostics

N/V
emotional lability
impaired coordination
facial flushing/ diaphoresis
resp depression
electrolyte imbalance
nystagmus/ diplopia
hypotension
hypoglycemia
coma

Blood level

50 – 100%: mild toxicity
100 – 300% moderate toxicity
more than 300% severe toxicity

Alcohol toxicity management

ABC’s
hemodialysis to reduce ethanol levels
IV glucose
Thiamine for at least 3 days
multivitamin/ folic acid/ fluids/ electrolytes

Antidysrhythmic drug overdose findings and diagnostics
(From Lidocaine, Procainamide, etc)

N/V
diarrhea
blurred vision
bradycardia
hypotension
cardiovascular collapse
tinnitus
delirium/ psychosis
serum levels may confirm overdose
bradycardia with AV block
prolonged QRS
ventricular arythmia’s – Torsade’s
Acute lung injury
low blood counts
drug induced lupus with procainamide

Antidysrhythmic drug overdose management

ECG
Charcoal with NG
For bradycardia: atropine or pacing
Isoproterenol to maintain HR greater than 60

Barbiturate overdose: what, findings, diagnostics
Phenobarbital

confusion
slurred speech
ataxia/ impaired coordination
CNS depression/ stupor
Drowsiness/ coma
Hypothermia
Resp depression
absent reflexes
miosis (pupil constriction)

Barbiturate overdose management

airway/ ventilation
charcoal for cooperative/ stable pt’s
hemodynamic support/ vasopressors

Benzodiazepine overdose: what, findings, diagnostics
Clonazepam, Diazepam

Drowsiness
confusion
slurred speech
unsteady gait
resp depression
hypoactive reflexes

Benzodiazepine overdose management

monitor BP and respiration
Flumazenil
gastric lavage

Betablocker and calcium overose: what, findings, treatment
Labetolol, metoprolol
Amlodipine, Nicardipine, Diltiazem

Bradycardia, hypotension, rhythm changes

Give Gluconate/ Glucagon and calcium chloride
Atropine for bradycardia
Monitor and treat electrolyes (K)
charcoal
ECG and possible pacing

carbon monoxide poisoning findings

SOB
HA
confusion/ ams
n/v
weakness
blurred vision
parkinsonism
dysrythmia’s
cardiac arrest
HF
resp depression
hypoxia
elevated carboxyhemoglobin level
Sinus tach
ST depression and PVC’s
metabolic acidosis

carbon monoxide poisoning management

100% O2 with mask or intubation
may require hyperbaric O2 if carboxyhemoglobin levels are greater than 25%, or pregnant, or ams

Opioid toxicity: what, findings, treatment
Codeine, heroin, methadone, opium, morphine, oxycodone

hypothermia
ams/ drowsiness/ coma
resp depression
miosis
ECG
ventilatory support
Narcan 0.4-2mg q2-3min

Lithium toxicity findings

n/v
muscle weakness/ tremor/ rigidity
ataxia
dementia/ delirium
lithium level greater than 1.5
hyperglycemia
AV-block/ prolonged QT
DI
seizures
leukocytosis
stupor/ coma

Lithium toxicity management

bolus NS
charcoal ineffective
gastric lavage for acute ingestion – within 1 hr
diuretics for lithium greater than 2-2 mEq
hemodialysis
benzodiazepine for seizures

Hymenoptera stings: what and findings
Bees, wasps, ants

Painful wheel/ hive from venom, IgE-mediated
anaphylaxis rare but possible
sever urticaria
bronchospasm/ laryngospasm
n/v
hypotension

Hymenoptera stings, management

Remove stinger (don’t squeeze/ pinch)
oral antihistamine (benadryl)
steroid taper (severe cases)

Anaphylaxis:

band application above sting with band (no occlusion of arterial artery)
ice area
elevate legs
epi 0.5-1mg q15min PRN respiratory compromise
benadryl 50mg IV once
Corticosteroid 250mg

Widowspider bite findings

pinprick
slightly red site
symptoms 1hr post bite
spasmodic muscle pain
resp distress
tachycardia
htn
n/v
ha
anxiety

Widowspider bite management

ice site
ABC’s
Dilaudid for pain
Lorazepam for muscle spasms

Brown spider bite findings

painless bite – unnoticed
2-8hrs post bite: red, pruritic, localized, painful swelling
12-18hrs post bite: small, vesicle with irregular border redness/ swelling
blister ruptures and redness becomes darker, spreading downward
5-7 days: necrosis
necrosis sloughs and leaves ulcer that takes weeks to heal

Children: systemic hemolysis

fever
ha
malaise
RF
shock
seizures
coma
death

Brown spider bite management

Ice site
daily, local wound care
tetanus prophylaxis

Scorpion sting findings

no allergic reaction
immediate, intense pain
swelling/ bruising
Systemic signs:
hypersalivation
dysphagia
visual changes/ rolling eyes
resp distress
htn
muscle spasms/ paralysis

Scorpion sting management

ice site
analgesics
tetanus prophylaxis
ABC’s
may give b-blocker for svt
may give antivenin for severe symptoms

Dog, cat, human bites treatment/ facts

may cause infection, may rinse out with NS or LR to prevent infection
give prophylactic AB, augmentin
determine rabies status for animal bites
leave wounds to hands and le open
wound older than 6hrs, leave open

Palliative extubation, management

remove unnecessary treatment
treat pain (HR, RR, expression): morphine, fentanyl, versed
remove mechanical ventilation in stepwise fashion, while assessing and treating pain

ANA Code of Ethics for Nurses
-In all professional relationships, practices with compassion & respect
-Primary commitment is to patient, family, group, community
-Promotes, advocates, protects health, safety, & rights of patients
-Responsible & accountable for his/her own patient care practice
-Owes same duty to self as to others, with integrity, competence, growth
-Participates in improving ethical and safe, high quality health care environments
-Participates in advancement of profession with research
-Collaborates with other health professionals & public to protect human rights, reduce health disparities
-Profession of nursing, as represented by associations/members…responsible for values & integrity & shaping social policy

Autonomy
the right to make their own decisions based on their own beliefs and values, for the patient

Veracity
being completely truthful with patients;

nurses must not withhold the whole truth from clients even when it may lead to patient distress

Beneficence
Action should promote good

Non-malfeasance
Ethical concept requiring that an action do no harm, or do less harm than good

Justice
All patients have a right to be treated fair and equally by others.

AACN Clinical Standards for Acute Care Nurse Practitioners

perform comprehensive advanced health assessments
order and interpret the full spectrum of diagnostic tests and procedures
formulate a differential diagnosis to reach a diagnosis, and
order, provide, and evaluate the outcomes of interventions.

The ACNP provides comprehensive advanced nursing care across the continuum of health care services to meet the individualized needs of patients with acute, critical, and/or complex chronic health conditions.

ACNPs do not require physician supervision or oversight as may be defined in collaborative practice arrangements to fulfill their role.

The ACNP elicits relevant data and information concerning patients with acute, critical, and/or complex chronic illnesses or injury
The ACNP analyzes and synthesizes the assessment data in determining differential diagnoses for patients with acute, critical, and/or complex chronic illnesses or injury.
The ACNP identifies individualized goals and outcomes for patients with acute, critical, and/or complex chronic illness or injury
The ACNP develops an outcomes-focused plan of care.
The ACNP implements the interventions identified in the interprofessional plan of care for patients with acute, critical, and/or complex chronic illness or injury.
The ACNP evaluates the patient’s progress toward the attainment of goals and outcomes

AACN professional standards for Acute Care Nurse Practitioners

The ACNP evaluates his or her clinical practice in relationship to institutional guidelines, professional practice standards, and relevant statutes and regulations.
The ACNP maintains current knowledge of best practices.
The ACNP collaborates with the patient, family, and members of the interprofessional team across the continuum of care.
The ACNP integrates ethical considerations into all areas of practice congruent with patient and family needs and values and the ANA Code of Ethic
The ACNP engages in organizational systems and processes to promote optimal outcomes.
The ACNP incorporates evidence-based diagnostic strategies, therapies, and complementary health alternatives to achieve optimal fiscally responsible outcomes.
The ACNP leads in the practice setting and in the profession.
The ACNP promotes respect for colleagues and the interprofessional team through the implementation of standards supporting a healthy work environment.
The ACNP evaluates and enhances the quality, safety, and effectiveness of care across the continuum of acute care service
The ACNP enhances knowledge, attitudes, and skills through participation in research, translation of scientific evidence, and promotion of evidence-based practice.

ICD 10 vs CPT
The ICD-10 procedural coding system (ICD-10-PCS) is used by facilities (e.g., hospital) to code procedures. CPT codes are, and will continue to be, used by physicians (and other providers) to report professional services.

credentialing vs privileges
Credentialing is a formalized process that incorporates established guidelines to confirm that a health care provider possesses sufficient qualifications, licensure, training, and abilities to practice at a nationally approved standard of care.

Privileging is a process that authorizes a provider to perform a specific set of care services that the agency determines the provider is qualified to perform

Macule
A circumscribed, flat area of discoloration that is less than 10 mm* in diameter.

Example: Freckle

Patch
A circumscribed, flat area of discoloration that is greater than 10 mm* in diameter. Slight scale may or may not be present.

Example: Vitiligo

Papule
A circumscribed, elevated, solid lesion that is less than 10 mm* in diameter.
Example: Wart

plaque
A circumscribed, elevated, solid lesion that is greater than 10 mm* in diameter and is usually broader than it is thick.

Example: Psoriasis

Weal
Transient, circumscribed, edematous papules or plaques caused by swelling in the dermis. Wheals may manifest with erythematous borders and pale centers and/or a narrow peripheral zone of pallor or vasoconstriction.

Example: Urticaria

Ulcer
A circumscribed loss of the epidermis and at least upper dermis. Ulcers are further classified by their depth, border, shape, edge, and the tissue at its base.

Example: Venous stasis ulcer

Bulla
A large, raised, circumscribed blister that is greater than 10 mm* in diameter and is fluid filled. The fluid can be clear, serous, hemorrhagic, or purulent.

Example: Pemphigus vulgaris

Cyst
A closed cavity or sac containing fluid or semisolid material. A cyst may have an epithelial or endothelial lining.

Example: Epidermal inclusion cyst

Pustule
A purulent (pus filled) vesicle. Pustules are filled with neutrophils and may be white or yellow. Not all pustules are infected.

Example: Bacterial folliculitis

Vesicle
A small, superficial, circumscribed blister that is less than 10 mm* in diameter and is fluid filled. The fluid may be clear, serous, hemorrhagic, or purulent.
Example: Herpes zoster

Purpura
Bleeding into the skin that results in violaceous (violet or purple) discoloration that varies according to its duration and does not blanch with pressure. Purpura includes petechiae and ecchymoses. When purpuric lesions are palpable, they represent vasculitis (vascular inflammation).

Example: Henoch-Schönlein purpura

petechiae
Tiny, 1- to 2-mm (pinpoint to pinhead size) nonblanchable purpuric macules resulting from the rupture of small blood vessels. Color may be red, purple, or brown.

Example: Rocky Mountain spotted fever

(NURS 6560 Final)
Question: The AGACNP is reviewing a chart of a head-injured patient. Which of the following would alert the AGACNP for the possibility that the patient is over …, thereby increasing the risk for increased intracranial pressure? NURS 6560 Final
Question: A patient who has … in the intensive care unit for 17 days develops hyponatremic hyperosmolality. The patient weighs 132 lb (59.9 kg), … , and is receiving mechanical ventilation. The serum osmolality is 320 mOsm/L kg H2O. Clinical signs include tachycardia and hypotension. The adult-gerontology acute care nurse practitioner’s initial treatment is to:
Question: A 16-year-old male presents with fever and right lower quadrant discomfort. He complains of nausea and has had one episode of vomiting, but he denies any diarrhea. His vital signs are as follows: temperature 101.9°F, pulse 100 bpm, respirations 16 breaths per minute, and blood pressure 110/70 mm Hg. A complete blood count reveals a WBC count of 19,100 cells/µL. The AGACNP expects that physical examination will reveal: NURS 6560 Final
Question: Myasthenia gravis is best … as:
Question: Coates is a 65-year-old female who is on postoperative day 1 following a duodenal resection for a bleeding ulcer. She had an uneventful immediate postoperative course, but throughout the course of day 1 she has … of a mild abdominal discomfort that has … throughout the day. This evening the AGACNP is … to the bedside to evaluate the patient for persistent and progressive discomfort. Likely causes of her symptoms include all of the following except:
Question: Coates is a 65-year-old female who is on postoperative day 1 following a duodenal resection for a bleeding ulcer. She had an uneventful immediate postoperative course, but throughout the course of day 1 she has complained of a mild abdominal discomfort that has … throughout the day. This evening the AGACNP is … to the bedside to evaluate the patient for persistent and progressive discomfort. Likely causes of her symptoms include all of the following except: NURS 6560 Final
Question: When a patient is … with a possible stroke, the AGACNP recognizes that the stroke most likely resulted from a subarachnoid hemorrhage when the patient’s family reports that the patient:
Question: You are … a 29 year old female complaining of abdominal pain. She states she is experiencing constant RUQ pain that radiates to her back. The pain is not … by bowel movements, over the counter antacids or food. Review of initial labs shows elevated amylase and lipase and you diagnose her with acute pancreatitis. Which test will you order next to determine the underlying cause of her pancreatitis?
Question: Jake is a 32-year-old patient who is recovering from major abdominal surgery and organ resection following a catastrophic motor vehicle accident. Due to the nature of his injuries, a large portion of his jejunum had to … resected. In planning for his recovery and nutritional needs, the AGACNP considers that:
Question: A 32-year-old man comes to the clinic because he has had pain in the back for the past 24 hours. The patient says he first … the pain when he awoke in the morning and had difficulty getting out of bed. He had been playing flag football the day before the pain began but did not sustain any injuries during the game. Acetaminophen has provided only minimal relief of the patient’s pain. On physical examination, pain is … on palpation of the back on the left, lateral to the region of L2-L5. Full range of motion is … in vertebral flexion, extension, lateral rotation, and lateral bending, with some hesitancy because of pain on the left side. Which of the following is the most appropriate initial step?
Question: On postoperative day 7 following hepatic transplant, the patient evidences signs and symptoms of acute rejection, confirmed by histologic examination. The AGACNP knows that first-line treatment of acute rejection consists of: Cyclosporine
Question: W. is a 33-year-old female who is being … after a fall from a tree. Anteroposterior and lateral radiographs of the thoracolumbosacral spine are significant for transverse process fractures at T6 and T7. The AGACNP knows that treatment for this likely will include:
Question: Acute hepatitis A is usually diagnosed by: NURS 6560 Final
Question: A 30-year-old male patient presents for evaluation of a lump on his neck. He denies pain, itch, erythema, edema, or any other symptoms. He is ^concerned because it won’t ^ go away. He says, “I noticed it a few months ago, then it seemed to disappear, and now it is back.” The AGACNP proceeds with a history and physical exam and concludes which of the following as the leading differential … ?
Question: E. is a 61-year-old female who presents for a postoperative visit following a gastric resection after a perforation of peptic ulcer. She reports feeling better, although it is taking longer than she expected. However, she says she is feeling better each day, her appetite is returning, and her incision is healing well. She is being … from surgical care and advised to continue her routine health promotion follow-up with her primary care provider. As part of her surgical discharge teaching, the AGACNP counsels P. E. that as a result of her gastric resection she will need lifelong follow-up of: Blood group substances
Question: O. is a 31-year-old male patient who is transported to the emergency department via emergency services. He was in a multivehicle accident and was trapped in a crushed car for more than 3 hours. On examination, his right lower extremity is found to … tensely swollen, with 3+ nonpitting edema. The lower leg is profoundly painful with passive range of motion. Given the history and physical findings, the AGACNP recognizes that treatment centers around:
Question: While consulting on a patient who is admitted with a chief complaint of abdominal pain, the AGACNP notes that the initial assessment … the pain as “colicky.” This means that the pain:
Question: All of the following are … findings in a patient with a T10 fracture except:
Question: O. is a 44-year-old female patient who presents for evaluation of sudden, severe upper abdominal pain. She is clear about the onset, which was profound and occurred approximately one hour ago. She denies that the onset had anyrelationship to food or eating, and she denies nausea or vomiting. On examination, she is lying on her right side with her hips and knees … to draw her knees to her chest. Vital signs are stable, but examination reveals involuntary guarding. The abdomen is painful and tympanic to percussion in all quadrants. CBC reveals a white blood cell count of 15,600/µL. The AGACNP suspects:
Question: The AGACNP is covering an internal medicine service and is paged by staff to see a patient who has just pulled out his ET tube. After the situation has been …, it is clear that the patient will go into respiratory failure and likely die if he is not reintubated. The patient is awake and alert and is adamant that he does not want to … reintubated. The AGACNP is concerned that there is not enough time to establish a DNR—the patient needs to … reintubated immediately and already is becoming obtunded. Which ethical principles are in conflict here?
Question: In myelodysplastic syndromes, the primary indications for splenectomy include:
Question: Which of the following situations constitute a positive screening after a PPD (purified protein derivative) skin test for tuberculosis?
Question: When the patient with jaundice is evaluated, a careful history and physical exam often can help differentiate prehepatic, hepatic, and posthepatic causes. When the patient reports dark discoloration of the urine and light discoloration of the stool, the AGACNP is most suspicious for:
Question: Jack R. is a 63-year-old male who is being … today on rounds after being … for profound upper abdominal pain, nausea, and vomiting. He had markedly elevated serum amylase and lipase; he was diagnosed with pancreatitis and admitted for pain management and bowel rest. Today he feels better, but he is upset because he knows that pancreatitisis … as the “alcoholic’s disease. ”He makes it clear that he is a religious man and that his religion forbids alcohol; he says he has never had an alcoholic drink in his life. The AGACNP reassures Jack that approximately 40% of cases of pancreatitis arecaused by as well as a variety of other things, and that he will have a thorough diagnostic evaluation.
Question: In neurogenic shock, patients are … to an abnormal dilation of venules and arterioles in response to failure of the autonomic nervous system. Treatment for neurogenic shock may include all of the following except: Trendelenburg
Question: Which of the following is a true statement with respect to the use of corticosteroids in posttransplant patients? High-dose initial steroids are … to off over a period of 4 to 6 weeks posttransplant
Question: The comprehensive serologic assessment of a patient with Cushing’s syndrome is likely to produce which constellation of findings?
Question: A patient admitted for management of sepsis is critically ill and wants to talk with a hospital representative about donating hero rgansifshedies. She has a fairly complex medical history that includes traumatic brain injury,breast cancer, and dialysis-dependent renal failure. The patient is … that she is ineligible to donate due to her: Renalfailure
Question: Elmerisa61-year-old male who is … vomiting bright red blood. He has no … medical history—he has not been in the health care system for most of his adult life. He has lost a lot of volume, and his vital signs are borderline unstable with a blood pressure of 88/58 mm Hg, pulse of 118 bpm, respiratory rate of 12 bpm, and a temperature of 97.6°F. The AGACNP recognizes that the leading differentials include all of the followingexcept:
Question: S. is a 31-year-old female who is … following a catastrophic industrial accident. She had multiple injuries, and after a 10-day hospital stay that included several operations and attempts to save her, she is declared brain dead. She had an organ donor notation on her driver’s license. Which of the following circumstances precludes her from serving as a liver donor?
Question: N. is a 61-year-old male who is referred to the emergency department by a local retail clinic. M. N. has not had regular health care at any time in his adult life; he says he doesn’t know when he last saw a doctor. His daughter finally talked him into going to the local retail health clinic when his abdomen became so … that he couldn’t pull his pants up. M. N. says that he has put on some weight over the last few weeks but he has not felt ill. He admits to drinking> 4 drinks of whiskey daily; he says he smokes 2 packs of cigarettes a day and is not very active. He has … alone since his divorce 20 years ago. Physical examination reveals an adult male who is chronically ill in appearance and appears older than … age. His vital signs are within normal limits, and physical examination is significant only for obviousascites. Paracentesis and subsequent analysis of the fluid reveals an ascites LDH to serum LDH ratio of 0.8. The AGACNP knows that this ratio is highly suspicious for:
Question: The AGACNP is treating a patient with ascites. After a regimen of 200 mg of spironolactone daily, the patient demonstrates a weight loss of 0.75 kg/day. The best approach to this patient’s management is to:
Question: The AGACNP knows that following bilateral total adrenalectomy, the patient will require: Prednisone 15 mg qam and 10 mg qpm
Question: Josh is a 14-year-old male patient who presents for evaluation of blurred vision. His only significant injury is that over the weekend he was playing baseball and was hit in the side of the head by a flying ball. The hit was hard enough to knock him down, but he did not lose consciousness and had no remarkable symptoms. Now on Wednesday he presents with a dull headache that seems to … getting worse, and his mom wants to have him evaluated. Neurologic examination reveals a sluggish pupillary response. CT scan of the head reveals a 1 cm epidural hematoma. The AGACNP knows that the best approach to management would …:
Question: isa39-year-old female who presents with persistent abdominal discomfort. She denies actual pain but says she has this persistent sense of fullness in her abdomen that feels like it would go away if she could have a bowel movement. This finding is … as:
Question: Tim is an 20 year old junior at Notre Dame and injured his right knee during an intramural football game and comes to the ER complaining of severe pain. Tim tells you that he was setting up to pass the football when he was … and he immediately felt his knee “pop” and buckle as he fell. You, as the AGACNP, know the most important information to obtain from Tim is:
Question: Nguyen is an 84-year-old female who suffered a fall in her long-term care facility. After assessing possible reasons for her fall, a physical examination is … to look for injuries. Mrs. Nguyen has significant pain in her left upper arm and limited range of motion in her left shoulder; a shoulder trauma series is … to evaluate for which type of injury that … occurs in these circumstances?
Question: A general principle in surgical oncology is that the best approach to curative surgery in a fixed tumor requires:
Question: Intracranial pressure monitoring is … for a patient with a head injury. The patient’s arterial blood pressure is 92/50mmHg,and her intracranial pressure is 18 mm Hg. Using these values to calculate the patient’s cerebral pressure (CPP) the AGACNP determines:
Question: Jefferson is a 59-year-old male who presents to the emergency department complaining of severe abdominal pain. His medical history is significant for dyslipidemia, and he takes 40 mg of sim vastatin daily. He admits to drinking 6 to 10 bottles of beer nightly and to smoking 1½ packs of cigarettes a day. He denies any history of chest pain or cardiovascular disease. He was in his usual state of good health until a couple of hours ago, when he developed this acute onset of severe pain in the upper abdomen. He says that he tried to wait it out at home but it was so bad he finally came in. His vital signs are as follows: temperature 99.1°F, pulse 129 bpm, respirations 22 breaths per minute, and blood pressure 137/84 mm Hg. The abdomen is diffusely tender to palpation with some guarding but no rebound tenderness. The AGACNP anticipates that which of the following laboratory tests will … abnormal?
Question: S. is a 31-year-old male who complains of gastric discomfort that he notices mostly on an empty stomach; for example, if he works late and does not have the opportunity to eat, he notices that it happens. It feels better when he eats something or even if he just take TUMS®. Physical examination reveals a generally healthy adult male with normal vital signs. There is a bit of mild discomfort with deep palpation to the epigastrum, but otherwise the abdominal exam is normal. The AGACNP know that the most useful laboratory analyses will include:
Question: The AGACNP is rounding on a patient following splenectomy for idiopathic thrombocytopenia purpura. On postoperative day 2, a review of the laboratory studies is … to reveal:
Question: Carolyn C. has a history of Crohn’s disease and has been … with immunologic agents, with moderate success. Today she presents with severe abdominal pain that comes and goes in waves; it started shortly after she ate a little bit of cottage cheese and crackers. This has never happened before with her Crohn’s disease. She has difficulty localizing the pain but seems to indicate the general area of the umbilicus. She had one episode of diarrhea this morning.
Question: A 30 year old female nurse comes to your office with complaints of epigastric pain that awakens her at night. She admits to being under a lot of stress at work and takes 2400 mg of ibuprofen for menstrual cramps and low back pain 5-6 times a week, especially after heavy lifting. She smokes a pack of cigarettes a day. Her physical exam is unremarkable but she does have positive heme stools. She is … for an upper endoscopy which reveals a duodenal ulcer. Given this history,what is the most likely etiology of her ulcer?
Question: An open fracture is … an orthopedic emergency. Emergency room management of open fracture must include: Immediate covering with iodine-soaked gauze
Question: Grant Pass is a 20 year old downhill skier for the U. S Olympic team. He was on a practice run in Salt Lake City and caught a ski tip on a mogul and became air born and … into the padded barriers on the side of the course. He was momentarily stunned, but was walking around … and was conversant when the ski patrol paramedics …. The paramedics placed him on a backboard and began to slowly ski down to the end of the course where an ambulance was waiting to take him to the local trauma center. When Grant was placed in the ambulance, the paramedics noted that Grant was somnolent and not responsive to verbal commands. They noted that his left pupil was dilated and sluggish to respond to light. … on the above information, you, as the ACNP in the ER, suspect that Grant … which of the following?
Question: Maroldo is an 81-year-old female who presents for evaluation of pain in her left lower quadrant. She has had this pain before and says she usually takes antibiotics and it goes away. However, this time it seems worse, and she has had it for 4 days even though she says she … taking her leftover antibiotics from the last episode. She denies any nausea or vomiting but says she simply isn’t hungry. She had a little diarrhea yesterday but no bowel movements today. She has a temperature of 100.9° F and a pulse of 104 bpm, respirations of 20 breaths per minute, and a blood pressure of 94/60 mm Hg. She has some discomfort to deep palpation in the left lower quadrant. The AGACNP suspects:
Question: G. is a 48-year-old female who presents with biliary colic. She has had previous episodes but has resisted operation because she is afraid of anesthesia. Today her physical exam reveals a clearly distressed middle-aged female with right upper quadrant pain, nausea, and vomiting. Which of the following findings suggests a complication that requires a surgical evaluation?
Question: Tim is an 20 year old junior at Notre Dame and injured his right knee during an intramural football game and comes to the ER complaining of severe pain. Tim tells you that he was setting up to pass the football when he was tackled and he immediately felt his knee “pop” and buckle as he fell. What physical exam tests would you perform to confirm your differential diagnosis?
Question: The AGACNP rounds on his brain injury patient and recognizes the development of progressive bradycardia, hypertension, and irregular respiratory pattern. This is … as Cushing’s triad and suggests:
Question: Justin F. is … in the emergency department with an 8-cm jagged laceration on the dorsal surface of his right forearm. He says he was working with his brother-in-law yesterday morning building a deck on the back of his home. A pile of wooden planks fell on top of him, and he sustained a variety of cuts and superficial injuries. He cleaned the wound with soap and water but didn’t want to go to the emergency room because he didn’t want to risk being in the waiting room for hours. He wrapped up his arm and went back to work, and then … a normal shower and went to bed last night. This morning the cut on his arm was still flapping open, and he realized he needed sutures. The appropriate management of this patient includes:
Question: A 49 year old female is … for sudden onset severe abdominal pain 10/10. On further questioning you learn that she has … epigastric pain for several months after eating, which has … in an 11 pound weight loss. She does not take any other medications. On physical exam you note she has a low grade fever of 100.1, HR 124, RR 25 and BP is 116/72. The abdomen is rigid and there are no bowel sounds. Abdominal plain film shows free air under the diaphragm. What is your diagnosis?
Question: R. is a 71-year-old female who presents with left lower quadrant pain that started out as cramping but has become more constant over the last day. She reports constipation over the last few days but admits that for as long as she can remember she has had variable bowel habits. Her vital signs are normal, but physical examination reveals some tenderness in the left lower quadrant. What is the leading diagnosis for this patient?
Question: T. is a 49-year-old male who has been admitted for the management of an episode of diverticulitis. This is his fifth hospitalization this year, and in previous hospitalizations he has had both abscess and stricture as a consequence of his disease. His treatment this hospitalization should include:
Question: Sara S. is a 41-year-old patient who has just had a bone marrow transplant. The AGACNP knows that which medication will … to decrease her risk of graft-versus-host reaction?
Question: The AGACNP is receiving report from the recovery room on a patient who just had surgical resection for pheochromocytoma. He knows that which class of drugs should … available immediately to manage hypertensive crisis, a possible consequence of physical manipulation of the adrenal medulla?
Question: A 41-year-old male physician has a 6-week history of persistent painful, swollen, and stiff proximal interphalangeal joints, wrists, and ankles. Using a step wise progression model, which would … the first diagnostic test the AGACNP would order?
Question: S., a 49-year-old male, is brought to the emergency room by his roommate who relates that the patient has been vomiting bright red blood for two days. He has a history of alcohol abuse. Current vital signs are as follows: Temp 99.2o F, heart rate 110 bpm (sinus tachycardia), blood pressure 90/60 mm Hg, resp 32 bpm. He is alert but lethargic and denies current abdominal pain. Which of the following is not … in the initial management of this patient?
Question: A 38-year-old patient presents with symptoms of L5 nerve root impairment that have been ongoing for 3 weeks despite conservative treatment. All of the following statements regarding this case are true EXCEPT:
Question: R. is a 71-year-old female who presents with left lower quadrant pain that … out as cramping but has become more constant over the last day. She reports constipation over the last few days but admits that for as long as she can remember she has had variable bowel habits. Her vital signs are normal, but physical examination reveals some tenderness in the left lower quadrant. Which diagnostic test is most likely to support the leading differential diagnosis?
Question: A patient with chronic hepatic encephalopathy is … home. Discharge teaching centers upon long-term management strategies to prevent ammonia accumulation. Teaching for this patient includes instruction about:
Question: Carpenter is a 28-year-old female who presents in significant pain; she indicates that the discomfort is in the right lower quadrant. The discomfort is colicky in nature and has the patient in tears. Which of the following … findings increases the index of suspicion for ureteral colic?
Question: A 32-year-old patient who under went an open splenectomy for a ruptured spleenis preparing for discharge. An adult- gerontology acute care nurse practitioner reviews the potential complications with the patient. The nurse practitioner emphasizes which instruction to the patient?
Question: When evaluating a patient with acute pancreatitis, which of the following physical or diagnostic findings is an ominous finding that indicates a seriously ill/potentially moribund patient?
Question: Ted is a 22 year old male who fell on his right shoulder 2 days ago during a martial arts class. He is complaining of inability to sleep on his right side and has pain whenever he tries to use his arm. He denies any sensory changes in his hand. Nothing seems to make it better, even the ibuprofen he has been taking several times a day.
Question: Based on the radiograph below, what is your working diagnosis at this time? NO PICTURE SHOWN:
Question: W. is a 50-year-old woman who presents for surgical resection of the liver for treatment of metastatic colon cancer. Preoperatively, the surgeon tells her that he is planning to remove 50 to 75% of her liver. The patient is concerned that she will not … able to recover normal liver function with that much removed. The AGACNP counsels her that:
Question: Joshua is a 31-year-old man who presents for evaluation of acute numbness and tingling and … strength in his arms. It happened rather suddenly this afternoon and has never happened before. The lower extremities do not appear to … affected. While performing the history the AGACNP asks specific questions about the risk of:
Question: The AGACNP is taking report on a head injured patient. The report includes scoring on the Glasgow Coma Scale of E2 M3 V5. How would you interpret this information?
Question: S. is a 49-year-old female with a history of colorectal cancer for which she has had surgical resection and chemotherapy. She presents with profound abdominal pain. She has not …, and she is not certain when she had her last normal bowel movement; her bowel habits have been irregular for some time. A CBC demonstrates a mild microcytic anemia but is otherwise normal; her WBC differential is normal. Results of a metabolic panel support minor volume contraction but show no significant electrolyte abnormalities. Abdominal radiographs demonstrate dilation of the proximal colon, air fluid levels, and a complete absence of air in the rectum. The AGACNP diagnoses the patient with: Perforated colon
Question: Tim is an 20 year old junior at Notre Dame and injured his right knee during an intramural football game and comes to the ER complaining of severe pain. Tim tells you that he was setting up to pass the football when he was tackled and he immediately felt his knee “pop” and buckle as he fell. Which of the following diagnostics would the AGACNP order first?
Question: Jane S. is a 35-year-old female patient who is at 30 weeks’ gestation. She is … regularly for prenatal care and has always been healthy; she just had an office visit and was told everything was fine. Tonight she presents to the emergency room complaining of significant pain in the upper abdomen. Her vital signs reveal a temperature of 98.4°F, pulse of 110 bpm, respirations of 20 breaths per minute, and blood pressure of 144/90 mm Hg. A urinalysis reveals proteinuria, and a metabolic panel is significant for increased transaminases. Her hemogram is normal, but the CVC reveals platelets of 85,000. The AGACNP knows that which of the following must … evaluated as a cause of her abdominal pain?
Question: A 52-year-old male comes to the clinic in preparation for an overseas trip next year. He has already searched the internet and knows that Hepatitis A and Hepatitis B are endemic in the country that he will … visiting. What will you recommend to this patient?
Question: Warner is a 64-year-old male who presents with multiple skin lesions scattered about his head, neck, shoulders, and arms. They range in size from 3 mm to 1.2 cm. They do not hurt, burn, or itch, but they are rough to palpation—like sandpaper. Mr. Warner has a history of basal cell carcinoma × 3 and wants to know if these are also skin cancer. The AGACNP tells him that these lesions may … precancerous and are … as:
Question: Brad Berry, a 30-year-old male, presents to the ED with the chief complaint of a red, hot, swollen, painful right knee. He first noticed the problem last night, and feels it has gotten worse over the past 14 hours.Your medical history reveals that Mr. Berry denies problems with any other joints or recent injury to his right knee. He is not sexually active and currently is attending seminary school. He denies urethral discharge or urinary symptoms, recent rash, IV drug use, chronic illness, or recent camping. His temperature is 102.2 F. Physical exam reveals normal general survey, cardiorespiratory and abdominal examination. The right knee is markedly swollen with + fluid wave. There are no inguinal lymph nodes palpated. Which of the following would … the first diagnostic test for the AGACNP to order?
Question: The AGACNP screens a new admit patient for liver disease. Elevations of all of the following would confirm your suspicion that this patient has liver disease, EXCEPT
Question: C. is a 60-year-old female with primary hyper aldosteronism. She has been … to your service for surgical management. Anticipated findings on clinical history would include:
Question: Janice is a 32-year-old female who presents for evaluation of abdominal pain. She has no significant medical or surgical history and denies any history of ulcers, reflux, or gastritis. However, she is now in significant pain and is afraid something is “really wrong.” She describes what … out as a dull discomfort in the upper part of her stomach a few hours ago but has now become more profound and centered on the right side just under her ribcage. She has not vomited but says she feels nauseous. Physical exam reveals normal vital signs except for a pulse of 117 bpm. She is clearly uncomfortable, and palpation of the abdomen reveals tenderness with deep palpation of the right upper quadrant. The AGACNP orders which imaging study to investigate the likely cause? NURS 6560 Final
Question: The AGACNP knows that early diagnostic findings consistent with rheumatoid arthritis include:
Question: The ethical principle of veracity refers to:
Question: Huckabee is a 51-year-old male who had a CT scan of the abdomen to evaluate refractory left lower quadrant discomfort. The scan reported an incidental finding of cholelithiasis with calcified gallbladder. While counseling Mr. Huckabee about the results, the AGACNP advises that the appropriate approach to these findings is:
Question: Miller is a 56-year-old male who is being managed for portal hypertension. The AGACNP knows that of the many causes of portal hypertension, alcoholic liver disease typically is the cause when the patient has: NURS 6560 Final
Question: Neoadjuvant chemotherapy treatment for cancer is given to facilitate surgical resection. When the outcomes of cancer therapies are …, the terms complete response and partial response often are … Partial response means that:
Question: Teller presents with a chief complaint of weight loss. She reports an … 10 lb weight loss over the last 5-6 months. She has no significant medical history, but review of systems reveals bilateral shoulder discomfort and some impaired range of motion — she has trouble pulling clothing over her head. Over the last few months she has generalized upper body stiffness, but seems to get better after an hour or so of activity. When considering a diagnosis of polymyalgia rheumatica, laboratory assessment may … to reveal:
Question: R. is a 52-year-old female who presents complaining of significant abdominal pain, which she rates as 8 to 9 on a 1 to 10 scale. The pain has been going on for a matter of hours, and she is afraid it won’t go away on its own. She denies any nausea or vomiting, and she cannot remember precisely when her last bowel movement …; probably it was a few days ago. She reports that she is “always” … On physical examination, she is tachycardic but otherwise has normal vital signs; her abdomen is tensely rigid, but no point tenderness to palpation is … The entireabdomen percusses as tympanic—there is no distinct dullness over the upper quadrants. Bowel sounds are present but hypoactive and intermittent. There is rebound tenderness to palpation. The AGACNP suspects:
Question: A patient with suspected Cushing’s syndrome is being … diagnosis and cause. Patients with an adrenal tumor typically will demonstrate:
Question: A 25-year-old medical student is stuck with a hollow needle during a procedure on a patient … to have hepatitis B viral infection but who is HIV-negative. The student’s baseline laboratory studies include serology: HBsAG negative, total Anti-HBc negative, IgM Anti-HBc -, Anti-HBs +. Which of the following is true regarding this medical student’s hepatitis status? NURS 6560 Final
Question: A 55-year-old man with a past medical history of hypertension and hyperlipidemia presents to your office with an acute onset of fevers, chills, dysuria, urinary frequency and right CVA tenderness. On exam he appears to … moderately ill, with a temperature of 39.3°C, pulse of 105/min and a blood pressure of 115/60mmHg. His cardiopulmonary and abdominal exam are negative. A urine dip in the office reveals 2+ blood, 2+ leukocytes and negative nitrates. Of the following tests, which is most likely to lead to the correct diagnosis? NURS 6560 Final
Question: R. is a 51-year-old male patient who is being … for fatigue. Over the last few months he has noticed a marked decrease in activity tolerance. Physical examination reveals a variety of ecchymoses of . origin. The CBC is significant for a Hgb of 10.1 g/dL, an MCV of 72 fL and a platelet count of 65,000/µL; the remainder of … the CBC is normal. Coagulation studies are normal, but bleeding time is … The AGACNP recognizes that initial management of this patient will include:
Question: Elliotis a 47-year-old male who is being …for throat cancer with combination therapy that includes radiation. He is asking questions about what adverse effects he may anticipate. The AGACNP advises Elliot that the most significant toxic effects in the acute / early post radiation period are:
Question: The AGACNP knows that when evaluating a patient with … acute pyelonephritis, which of the following is not a common feature? NURS 6560 Final
Question: D. is a 13-year-old male patient who has a history of recurrent fever and flank pain. His parents traditionally are not believers in the health care system, and he has not been … by a health care provider for many years. Today he has fever, chills, and costovertebral angle tenderness. Urinalysis reveals findings consistent with acute urinary infection. The AGACNP treats the patient for pyelonephritis and considers which study to evaluate for vesicoureteral reflux?
Question: Maxine is being … in follow-up after removal of an aldosteronoma. The AGACNP expects specifically that which of the following aldosterone-related abnormalities will … cured?
Question: Acute hepatitis B is diagnosed by: NURS 6560 Final
Question: A 19-year-old woman presents to your office with a 3-day history of dysuria and foul-smelling urine. She also notes some suprapubic pressure and noted some chills and she thinks she had a fever yesterday. She reports no vaginal bleeding or discharge and reports no nausea or vomiting. She denies any significant past medical history. On exam she has a temperature of 38°C, a pulse of 105/min and a blood pressure of 120/75 mm Hg. Her abdominal exam reveals some suprapubic tenderness. Her back exam reveals no cost over tebral angle tenderness. Urine dip demonstrates 2+ leukocytes. What should … done next?
Question: Brad Berry, a 30-year-old male, presents to the ED with the chief complaint of a red, hot, swollen, painful right knee. He first … the problem last night, and feels it has gotten worse over the past 14 hours.Your medical history reveals that Mr. Berry denies problems with any other joints or recent injury to his right knee. He is not sexually active and currently is attending seminary school. He denies urethral discharge or urinary symptoms, recent rash, IV drug use, chronic illness, or recent camping. His temperature is 102.2 F. Physical exam reveals normal general survey, cardiorespiratory and abdominal examination. The right knee is … swollen with + fluid wave. There are no inguinal lymph nodes palpated. In your immediate consideration of differential diagnoses for Mr. Berry’s knee problem, … the least likely? NURS 6560 Final
Question: The AGACNP is evaluating a 79-year-old male in the emergency department. He is extremely anxious and requires significant reassurance that he is not going to die. He subsequently rules in for an anterolateral myocardial infarction. His daughter asks you not to tell the patient the truth. She is afraid that it will compound his anxiety, agitate him, andworsenhiscondition.TDNEpUTHQoQUJMHLrErGJyHg89uy71MyuHbetoldpreciselywhathisconditionis.Themost appropriate action would … to:
Question: Knicker son is a 77-year-old female admitted for management of urinary tract infection. Her complete blood count reveals a white blood cell differential as follows: Total leukocyte count 57,000 cells/uL, neutrophils of 16%, lymphocytes 77%, monocytes 3%, eosinophils 3% basophils 1%. The AGACNP is suspicious for: NURS 6560 Final
Question: A 54-year-old man with a history of metastatic lung cancer comes to the office because he had sudden onset of pain in the lower back and both legs 24 hours ago. Which of the following findings would indicate that a lumbar disk herniation rather than a cauda equina syndrome is the cause of his pain?
Question: The Ranson’s Criteria of Severity is a morbidity and mortality index … to predict risk in patients with acute pancreatitis. A Ranson score of 3 indicates:

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