SLK 310(B) THEME 3: SOMATOFORM & DISSOCIATIVE DISORDERS
Notes of Theme 3 (Somatoform & Dissociative Disorders) as covered in the SLK310(B) module
SLK 310(B) THEME 3: SOMATOFORM & DISSOCIATIVE DISORDERS
Notes of Theme 3 (Somatoform & Dissociative Disorders) as covered in the SLK310(B) module
SLK110 - Chapter 15 Abnormal Behaviour
Summary of Chapter 15. Includes Foundations and Definitions, Anxiety Disorders, Obsessive Compulsive and related disorders, Trauma-and Stressor related disorders, Dissociative disorders, Depressive and Bipolar related disorders, Somatic symptom and related disorders, Schizophrenia Spectrum-Related Disorders, Personality Disorders, Eating Disorders, Culture and Pathology.
Dissociative and Somatic Symptom Disorders
These notes offer a comprehensive look at the various Dissociative and Somatic Symptom Disorders.
NUR2520 Psychiatric Nursing Exam #2 Study Guide
Questions and Answers for NUR2520 Psychiatric Nursing Exam #2:
1) In planning care for a suicidal client, which correctly written outcome should be a nurse's first priority?
2) A client diagnosed with major depressive disorder with psychotic features hears voices commanding self-harm. The client refuses to commit to developing a plan for safety. What should be the nurses priority intervention at this time?
3) After years of dialysis, an 84-year-old states, Im exhausted, depressed, and done with these attempts to keep me alive. Which question should the nurse ask the spouse when preparing a discharge plan of care?
4) A nursing student is developing a plan of care for a suicidal client. Which documented intervention should the student implement first?
6) Which nursing intervention strategy is most appropriate to implement initially with a suicidal client?
7) A nursing instructor is teaching about specific phobias. Which student statement indicates to the instructor that learning has occurred?
8) A client has a history of excessive fear of water. What is the term that a nurse should use to describe this specific phobia, and under what subtype is this phobia identified?
9) How would a nurse differentiate a client diagnosed with a social phobia from a client diagnosed with a schizoid personality disorder (SPD)?
10) A client refuses to go on a cruise to the Bahamas with his spouse due to fearing that the cruise ship will sink and all will drown. Using a cognitive theory perspective, how should a nurse explain to the spouse the etiology of this fear?
11) A nursing instructor is teaching about the medications used to treat panic disorder. Which student statement indicates that learning has occurred?
12) A client is experiencing a severe panic attack. Which nursing intervention would meet this client's physiological need?
14) A client is newly diagnosed with obsessive-compulsive disorder and spends 45 minutes folding clothes and rearranging them in drawers. Which nursing intervention would best address this client's problem?
15) A client who is experiencing a panic attack has just arrived at the emergency department. Which is the priority nursing intervention for this client?
18) How should a nurse best describe the major maladaptive client response to panic disorder?
The major maladaptive client response to panic disorder is the perception of having no control over life situations which leads to nonparticipation in decision making and doubts regarding role performance.
20) Studies have suggested that re-experiencing a traumatic event can become an addiction of sorts. The evidence suggests that the reason for this is:
21) A patient being treated for symptoms of PTSD following a shooting incident at a local elementary school reports I feel like there’s no reason to go on living when so many others died. Which of these is the most appropriate response by the nurse at this juncture?
22) Major Smith, who is being treated for PTSD symptoms following a course of military duty, reports, I think I was in denial about even having PTSD. I thought I was just having trouble sleeping. Which of these is an accurate evaluation of the patients comments?
23) Lorraine has been diagnosed with Somatic Symptom Disorder. Which of the following symptom profiles would you expect when assessing Lorraine?
24) Which are examples of primary and secondary gains that clients diagnosed with SSD: predominately pain, may experience?
25) A nursing instructor is teaching about the etiology of dissociative disorders from a psychoanalytical perspective. What student statement about clients diagnosed with this disorder indicates that learning has occurred?
26) An inpatient client is newly diagnosed with dissociative identity disorder (DID) stemming from severe childhood sexual abuse. Which nursing intervention takes priority?
27) A client diagnosed with dissociative identity disorder (DID) switches personalities when confronted with destructive behavior. The nurse recognizes that this dissociation serves which function?
28) Why are behavior modification programs the treatment of choice for clients diagnosed with eating disorders?
29) Family dynamics are thought to be a major influence in the development of anorexia nervosa. Which information related to a client's home environment should a nurse associate with the development of this disorder?
30) A potential Olympic figure skater collapses during practice and is hospitalized for severe malnutrition. Anorexia nervosa is diagnosed. Which client statement best reflects the underlying etiology of this disorder?
32) A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should a nurse identify as an appropriate indicator of a positive client behavioral change?
33) A nurse is seeing a client in an outpatient clinic for treatment of anorexia nervosa. Which is the most appropriate, correctly written short-term outcome for this client?
36) A nurse working with a client diagnosed with bulimia nervosa asks the client to recall a time in life when food could be consumed without purging. Which is the purpose of this nursing intervention?
37) A client diagnosed with anorexia nervosa stopped eating 5 months ago and lost 25% of total body weight. Which subjective client response would the nurse assess to support this medical diagnosis?
38) During an assessment interview, a client diagnosed with antisocial personality disorder spits, curses, and refuses to answer questions. Which is the appropriate nursing response to this behavior?
39) At 11:00 p.m. a client diagnosed with antisocial personality disorder demands to phone a lawyer to file for a divorce. Unit rules state that no phone calls are permitted after 10:00 p.m. Which nursing response is most appropriate?
40) During an interview, which client statement should indicate to a nurse a potential diagnosis of schizotypal personality disorder?
41) When planning care for a client diagnosed with borderline personality disorder, which self-harm behavior should a nurse expect the client to exhibit?
42) Which nursing diagnosis should be prioritized when providing nursing care to a client diagnosed with paranoid personality disorder?
43) The nurse should recognize which factors that distinguish personality disorders from psychosis?
44) Which client statement would demonstrate a common characteristic of Cluster "B" personality disorder?
SELECT ALL THAT APPLY
45) After a teenager reveals that he is gay, the father responds by beating him. The next morning, the teenager is found hanging in his closet. Which paternal emotions should a nurse anticipate? (Select all that apply.)
46) A nurse is admitting a client who has been diagnosed with PTSD. Which of the following symptoms might the nurse expect to assess? (Select all that apply.)
47) An adult male has sought counseling at a community mental health center for PTSD. He reports during assessment that he witnessed the murder of a close friend last year in a random, drive-by shooting in his neighborhood. Since this loss he has had recurrent nightmares, explosive episodes, and frequently incapacitating anxiety. Which of the following nursing diagnoses would be appropriate, based on this assessment data? Select all that apply.
48) Joe, a patient being treated for PTSD, tells the nurse that his therapist is recommending cognitive therapy. He asks the nurse how that's supposed to help his nightmares. Which of these responses by the nurse provides accurate information about the benefits of this type of therapy? Select all that apply.
49) A nurse should identify topiramate (Topamax) as the drug of choice for which of the following conditions? (Select all that apply.)
PSY2012 Module 8 Quiz latest 2018
Abusing alcohol is against one's best interests, as it can lead to very negative consequences in a number of areas. Alcohol abuse is therefore considered:
Recall the 3 Ds of psychological abnormality. Distress refers to the degree to which one's behaviors or emotions:
Interfere with relationships or daily life.
Are rare or unusual.
Make an individual uncomfortable and upset.
Fall outside society’s standards or rules.
A cultural disorder that is marked by a man fearing that his genitals are disappearing into his abdomen is known as:
In the cases in which it is used, the insanity defense is _____ successful.
The DSM-5 lists about _____ disorders.
The causes of psychological abnormality are complex. The view that MOST explicitly recognizes this fact is the _____ perspective.
The MOST prevalent anxiety disorder is:
Social anxiety disorder
Generalized anxiety disorder
Aidan is sweating and nauseous. His heart is racing, and he feels as if he might die. Aidan is suffering from:
Generalized anxiety disorder
Social anxiety disorder
Stan is focused on cleaning his home, which he does for several hours each day. In particular, the fringe on his rugs must be straight on both sides in all five rooms. This takes considerable time, and Stan often repeats his rug-straightening behavior 10 to 12 times each day. This behavior is an example of a(n):
To qualify as disordered, obsessions or compulsions must be disabling and consume at least _____ hour(s) each day.
Sam has gained weight lately. He feels hopeless and takes little pleasure in the activities he once enjoyed. Sam may be suffering from:
dissociative identity disorder
Which statement is TRUE?
Major depression is much more prevalent among men than among women.
Major depression is somewhat more prevalent among men than among women.
Major depression is more prevalent among women than among men.
Major depression is equally prevalent among men and women.
0 / 1 pts
A common psychological disorder among people who commit suicide is _____ disorder.
generalized anxiety disorder
antisocial personality disorder
Among individuals with major depressive disorder, cortisol levels are often:
Merrill feels elated and invincible; he seems to have boundless energy. Merrill may be in a _____ state.
Bipolar I disorder is to bipolar II disorder as _____ is to _____.
dysthymia; major depression
Irene hears voices inside her head. She believes they are the voices of NSA officials attempting to monitor and record her thoughts. These two sentences illustrate a _____ and a _____, respectively.
Elise has been diagnosed with schizophrenia. She has recently demonstrated significant social withdrawal symptoms. This is a _____ symptom of schizophrenia.
Which choice MOST accurately expresses the lifetime prevalence of schizophrenia in the general population?
less than 1 %
nearly 3 %
about 6 %
Contemporary psychologists believe that the origin of schizophrenia is:
about half genetic and half environmental.
NR 326 MENTAL HESI 6(Already graded A )
NR 326 MENTAL HESI 6
1. A nurse working in the emergency department of a children's hospital admits a child whose injuries could have been the result of abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse?
A. Obtain objective data such as radiographs before reporting suspicions.
B. Confirm suspicions of abuse with the healthcare provider.
C. Report any case of suspected child abuse.
D. Document injuries to confirm suspected abuse.
2. An 8-year-old child is seen in the clinic with a green vaginal discharge. What action is most important for the nurse to implement?
A. Assess the child's blood pressure.
B. Counsel the child to wear cotton underwear.
C. Report as suspected child abuse.
D. Determine if the child takes bubble baths.
3. On admission, a highly anxious client is described as delusional. The nurse understands that delusions are most likely to occur with which disorder?
A. Dissociative disorders
B. Personality disorders
C. Anxiety disorders
D. Psychotic disorders
4. Over a period of several weeks, one male participant of a socialization group at a community daycare center for older adults monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in this situation?
A. Talk to him outside the group about his behavior.
B. Ask him to give others a chance to talk.
C. Allow the group to handle the problem.
D. Ask him to join another group.
5. A 22-year-old female client is admitted to the psychiatric unit from the medical unit following a suicide attempt with an overdose of diazepam (Valium). When developing the nursing care plan for this client, what intervention would be most important to include?
A. Assist her to focus on her strengths.
B. Set limits on her self-defacing comments.
C. Remind her of daily activities in the milieu.
D. Assist her to identify why she was self-destructive.
6. The nurse reviews the laboratory findings for a client's urine drug screen that is positive for cocaine. Which client behavior should be expected during cocaine withdrawal?
A. Psychomotor impairment
B. Agitation and hyperactivity
C. Detachment from reality and drowsiness
D. Distorted perceptions and hallucinations
7. A 25-year-old client has suffered extensive burns and is crying during dressing change treatment. The client tells the nurse, "Please let me die. Why are you all torturing me like this? I just want to die." Which response by the nurse is best?
A. "We aren't torturing you. These treatments are necessary to prevent a terrible infection."
B. "I know these treatments must seem like torture to you, but we want to help you recover."
C. "You have so much to live for, and all of your family members want you to live."
D. "Would you like me to call the chaplain so that you can privately discuss your feelings?"
8. A 33-year-old client is admitted to a psychiatric facility with a medical diagnosis of major depression. When the nurse is assigning the client to a room, which roommate is best for this client?
A. A 35-year-old who recently attempted suicide
B. A manic client who has started lithium carbonate treatment
C. A client who is bipolar and is pacing the floor while telling jokes to everyone
D. A paranoid client who believes that the staff is trying to poison the food
9. A male client who was admitted 2 days earlier to a drug rehabilitation unit tells the nurse, "I'm going to do what you people tell me to do so I can get out of here and get a job." What is the most accurate interpretation of this client's statement?
A. The treatment program is effective and the client is highly motivated.
B. Defense mechanisms are being used to decrease anxiety.
C. Manipulation is being used to achieve the client's personal goals.
D. The client has insight into his behaviors, so privileges should be given.
10. A middle-aged client tells the clinic nurse, "I'm again starting to feel overwhelmed and anxious with all my responsibilities. I don't know what to do." Which is the best response for the nurse to make?
A. "Describe in more detail your feelings about being overwhelmed."
B. "Why don't you give up some of your commitments?"
C. "What has worked for you in the past?"
D. "I know, but it is important to take time for yourself."
11. The nurse admits a client with depression to the mental health unit. The client reports difficulty concentrating, has lost 10 pounds in 2 weeks and is sleeping 12 hours a day. Which outcome is most important for the client to meet by discharge?
A. Tries to interact with a few peers and staff
B. Reports feeling better and less depressed
C. Sits attentively with peers in group therapy
D. Easily awakens for morning medications
12. A 25-year-old female client has been particularly restless and the nurse finds her trying to leave the psychiatric unit. She tells the nurse, "Please let me go! I must leave because the secret police are after me." What response is best for the nurse to make?
A. "No one is after you. You're safe here."
B. "You'll feel better after you have rested."
C. "I know you must feel lonely and frightened."
D. "Come with me to your room and I will sit with you."
13. On admission, a depressed female client tells the nurse, "I can't eat because my tongue is rubber." Which is the best action for the nurse to implement?
A. Provide packaged foods for the client to eat.
B. Begin the client on total parenteral nutritional (TPN) therapy.
C. Provide a liquid diet for the client.
D. No action is necessary. The client will eat when she is hungry.
14. A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make?
A. "Did you really believe you were Jesus Christ?"
B. "I think you're getting well."
C. "Others have had similar thoughts when under stress."
D. "Why did you think you were Jesus Christ?"
15. The nurse notes multiple burns on the arms and chest of a 2-year-old Vietnamese child who is being treated for dehydration. When questioned, the child's father states that he treated the child's vomiting with the cultural practice called "coining," which resulted in burned areas. Which expected outcome statement has the highest priority?
A. The child will be protected from further harm.
B. The family's cultural values will be respected.
C. The parents will express regret at harming their child.
D. The parents will demonstrate ability to care for the burn wounds.
16. A client in the critical care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveals no significant changes, and the nurse formulates the diagnosis Confusion related to ICU psychosis. Which intervention is best to implement based on this client's behavior?
A. Move all machines away from the client's bedside at once.
B. Allay fears by teaching the client about disease etiology.
C. Cluster care to allow for brief rest periods during the day.
D. Encourage visitation by the client's family members.
17. Which ego-defense mechanisms are exhibited by a client with a phobia related to refusal to leave home?
18. The nurse is caring for a client who is taking the mood stabilizer divalproex sodium (Depakote). Which laboratory finding is most important to include in this client's record?
A. Liver function tests
B. Creatinine clearance
C. Complete blood count
D. Chemistry panel
19. Which topics should the nurse include in an education program for clients with schizophrenia and their families? (Select all that apply.)
A. Importance of adherence to medication regimen
B. Current treatment measures for substance abuse
C. Signs and symptoms of an exacerbation
D. Prevention of criminal activity
E. Behavior modification for aggression
F. Chronic grief associated with long-term illness
20. A female client in an acute care facility has been on antipsychotic medications for the past 3 days. Her psychotic behaviors have decreased and she has had no adverse reactions. On the fourth day, the client's blood pressure increases, and she becomes pale and febrile and demonstrates muscular rigidity. What action should the nurse initiate?
A. Place the client on seizure precautions and monitor frequently.
B. Take the client's vital signs and notify the healthcare provider immediately.
C. Describe the symptoms to the charge nurse and document them in the client's record.
D. No action is required at this time as these are known side effects of her medications.
21. A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad. No one can help me." Which response would be best for the nurse to make?
A. "How can I help you? Tell me more about your problems."
B. "Things probably aren't as bad as they seem right now."
C. "Let's talk about what is right with your life."
D. "I hear your misery, but things will get better soon."
22. What behavior indicates to the nurse that a male client with paranoid ideas is improving? The client
A. arrives on time for all activities.
B. talks more openly about his plans to protect his possessions.
C. aggressively uses the punching bag in the gym.
D. discusses his feelings of anxiety with the nurse.
23. A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last 6 months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. This client is displaying symptoms of which disorder?
24. A client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. What action should the nurse take?
A. Notify the healthcare provider immediately and force fluids.
B. Prior to giving the next dose, notify the healthcare provider of the symptoms.
C. Record the symptoms and continue medication as prescribed.
D. Hold the medication and refuse to administer additional amounts of the drug.
25. A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates her mannerisms. Which defense mechanism does the nurse recognize in this client?
26. A male client begins taking an atypical antipsychotic medication. The nurse must provide informed consent and education about common medication side effects. Which client education will be most important?
A. Maintain a balanced diet and adequate exercise.
B. Be sure the diet is adequate in salt intake.
C. Monitor for any changes in sleep pattern.
D. Report any unusual facial movements.
27. The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information would be most useful to the nurse when planning activities for the group?
A. Each resident's length of stay at this nursing home
B. A brief description of each resident's family life
C. The age and medication regimen of each group member
D. The usual activity patterns of each group member
28. A 35-year-old male client admitted to the psychiatric unit of an acute care hospital tells the nurse that he believes someone is trying to poison him. The client's delusions are most likely related to which factor?
A. Authority issues in childhood
B. Anger about being hospitalized
C. Low self-esteem
D. Phobia of food
29. A female client believes that her healthcare provider is an FBI agent and that her apartment is a site for slave trading. She believes that the FBI has cameras in her apartment, so she cannot return there. Based on these symptoms, which class of medication is the nurse most likely to find to be prescribed for this client?
A. Antianxiety medication
B. Mood stabilizer
30. A 27-year-old female client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. She is demanding and active. What intervention should the nurse include in this client's plan of care?
A. Schedule the client to attend various group activities.
B. Reinforce the client's ability to make her own decisions.
C. Encourage the client to identify feelings of anger.
D. Provide a structured environment with little stimuli.
31. A male schizophrenic client who is taking fluphenazine decanoate (Prolixin decanoate) is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation and will return in 18 days. Which statement by the client indicates to the nurse a need for health teaching?
A. "I am going to have lots of time in the sun."
B. "While I am on vacation, I will not eat or drink anything that contains alcohol."
C. "I will notify the healthcare provider if I have a sore throat or flu-like symptoms."
D. "I will continue to take my benztropine mesylate (Cogentin) every day."
32. During a home visit, a male client with schizophrenia reports hearing voices that tell him to walk in the middle of the street. The nurse records several statements made by the client. Based on which statement should the nurse determine that the client needs hospitalization?
A. "Sometimes I take an extra one of my pills when I hear the voices."
B. "The voices are louder when I forget to take my medication."
C. "No matter what I do, I can't make the voices go away."
D. "I just try to tell the voices to stop when they bother me."
33. An adult male client who lives in a residential facility is mentally retarded and has a history of bipolar disorder. During the past week, he has refused to wear clothes and frequently exposes himself to other residents. Which intervention should the nurse implement?
A. Establish a one-to-one relationship to discuss his behavior.
B. Redirect the client to physically demanding activities.
C. Encourage the client to verbalize his thoughts when acting-out.
D. Restrict social interactions with other residents in the facility.
34. The nurse is assessing a young female client admitted to the psychiatric unit for acute depression related to a recent divorce. Which statement is most indicative of a client suffering from depression?
A. "I'm not very pretty or likeable."
B. "I've lost 20 pounds in the past month."
C. "I like to keep things to myself."
D. "I think everyone is out to get me."
35. A 68-year-old female client, a retired secretary, is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal, "Assist client to express feelings of guilt." What is true about the goal statement referring to the client's depression?
A. Implementation of this goal should be deferred until further data can be gathered.
B. The depression is most likely age-related and will dissipate once she becomes accustomed to retirement.
C. Depressed clients are often unaware of guilt feelings and should be encouraged to increase self-awareness.
D. Nursing goals should be approved by the treatment team before they are initiated.
36. A male client on the psychiatric unit, diagnosed as bipolar disorder, becomes loud and shouts at one of the nurses, "You fat tub of lard, get something done around here!" What is the best initial action for the nurse to take?
A. Have the staff escort the client to his room.
B. Tell the client that his behavior will be recorded in his record.
C. Redirect the client by asking him to play card games with peers.
D. Review the medication record for an antipsychotic drug.
37. An individual with a known history of alcohol abuse is admitted for emergency surgery following a motor vehicle collision. The nurse includes in the client's plan of care, "Observe for signs of delirium tremens." What early signs indicate that the client is beginning to have delirium tremens?
A. Abdominal cramping and watery eyes
B. Depression and fatigue
C. Restlessness and confusion
D. Hostility and anger
38. A woman brings her 48-year-old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that these behaviors are often associated with which condition?
A. Dissociative disorder
B. Obsessive-compulsive disorder
C. Panic disorder
D. Posttraumatic stress syndrome
39. An adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate) because of medication noncompliance. What should the nurse teach the client and family about this change in medication regimen?
A. Long-acting medication is more effective than daily medication.
B. A client with substance abuse must not take any oral medications.
C. There will continue to be a risk of alcohol and drug interaction.
D. Support groups are only helpful for substance abuse treatment.
40. A client is admitted with a diagnosis of depression. The nurse knows that which characteristic is most indicative of depression?
A. Grandiose ideation
B. Self-destructive thoughts
C. Suspiciousness of others
D. Negative views of self
41. A female client mumbles out loud whether anyone is talking to her or not and she also mumbles in group when others are talking. The nurse determines that the client is experiencing hallucinations. Which intervention should the nurse implement?
A. Respond to the client's feelings rather than the illogical thoughts.
B. Identify beliefs and thoughts about what the client is experiencing.
C. Provide the client with hope that the voices will eventually go away.
D. Ask the client how she has previously managed the voices.
42. A child is brought to the emergency department with a broken arm. Because of other injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't you touch him! You'll hurt my child!" What is the best interpretation of the mother's statements? She is
A. regressing to an earlier behavior pattern.
B. sublimating her anger.
C. projecting her feelings onto the nurse.
D. suppressing her fear.
43. A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her room, she refuses to eat and tells the nurse, "I know you are trying to poison me with that food." What response by the nurse is the most therapeutic?
A. "I'll leave your tray here. I am available if you need anything else."
B. "You're not being poisoned. Why do you think someone is trying to poison you?"
C. "No one on this unit has ever died from poisoning. You're safe here."
D. "I will talk to your healthcare provider about the possibility of changing your diet."
44. Clients are preparing to leave the mental health unit for an outdoor smoke break. A client on constant observation cannot leave and becomes agitated and demands to smoke a cigarette. What action should the nurse take first?
A. Remind the client to wear the nicotine (NicoDerm) patch.
B. Determine if the client still needs constant observation.
C. Encourage the client to attend the smoking cessation group.
D. Explain that clients on constant observation cannot smoke.
45. The nurse develops a plan of care for a client with symptoms of paranoia and psychosis. The priority nursing diagnosis is Impaired social interactions related to inability to trust. Which intervention is most important for the nurse to implement?
A. Greet the client by first name during each social interaction.
B. Determine if the client is experiencing auditory hallucinations.
C. Introduce the client to peers on the unit as soon as possible.
D. Assign the client to a group about developing social skills.
46. At the first meeting of a group of older adults at a daycare center for older adults, the nurse asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, "You tell me. You're the leader." What would be the best response for the nurse to make?
A. "Yes, I am the leader today. Would you like to be the leader tomorrow?"
B. "Yes, I will be leading this group. What would you like to accomplish?"
C. "Yes, I have been assigned to lead this group. I will be here for the next 6 weeks."
D. "Yes, I am the leader. You seem angry about not being the leader yourself."
47. While in group therapy, a male client who is diagnosed with posttraumatic stress disorder (PTSD) is processing an experience from the war in Iraq when another client tips over a chair. What action should the nurse take when the client with PTSD falls to the floor in a fetal position?
A. Confront the client who tipped over the chair about the inconsiderate behavior.
B. Dismiss the other clients from the group therapy session for a 10-minute break.
C. Reinforce reality to the client on the floor and remove him to a quiet space.
D. Call a security code and medicate both clients with an antianxiety drug.
48. Physical examination of a 6-year-old boy reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse would be most appropriate?
A. "I need to tell the healthcare provider about your child's tendency to be accident prone."
B. "Tell me more about these accidents that your child has been having."
C. "I need to report these injuries to the authorities because they do not seem accidental."
D. "Boys this age always seem to require more supervision and can be quite accident prone."
49. A middle-aged adult was discharged from a treatment center 6 weeks ago following treatment for suicide ideation and alcohol abuse. In a follow-up visit to the mental health clinic, the client complains of lethargy, apathy, irritability, and anxiety. Which question is most important for the nurse to ask?
A. "Are you taking prescribed antidepressants?"
B. "How much alcohol do you consume daily?"
C. "What seems to precipitate the anxious feelings?"
D. "How many hours do you sleep per day?"
50. A 35-year-old male client who has been hospitalized for 2 weeks for paranoia complains continuously to the staff that someone is trying to steal his clothing. What is the correct action for the nurse to take based on this client's complaints?
A. Enroll the client in an exercise class to promote self-esteem.
B. Place a lock on the client's closet to deter any theft.
C. Promote extinction of the ideation by ignoring the client.
D. Explain to the client that these suspicions are false.
NR 326 MENTAL HESI 5 (Already graded A )
NR 326 MENTAL HESI 5
1. A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. His temperature is 100.0 F, pulse is 100, and blood pressure is 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis?
a. Risk for injury related to suicidal ideation.
b. Risk for injury related to alcohol detoxification.
c. Knowledge deficit related to ineffective coping.
d. Health seeking behaviors related to personal crisis.
2. A nurse working in the emergency room of a children's hospital admits a child whose injuries could have resulted from abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse?
a. Obtain objective data such as x-rays before reporting suspicions.
b. Confirm suspicions of abuse with the physician.
c. Report any case of suspected child abuse.
d. Document injuries to confirm suspected abuse.
3. A child is brought to the emergency room with a broken arm. Because of other injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't you touch him! You'll hurt my child!" What is the best interpretation of the mother's statements?
a. She is regressing to an earlier behavior pattern.
b. She is sublimating her anger.
c. She is projecting her feelings onto the nurse.
d. She is suppressing her fear.
4. A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. Which approach should the nurse take?
a. Ask the staff to escort the client to his room.
b. Have the client ask his physician to change his privileges.
c. Remind the client of the importance of following the rules.
d. Disregard the client's inappropriate verbal outburst.
5. A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms?
a. Perphenazine (Trilafon).
b. Diphenylhydramine (Benadryl).
c. Chlordiazepoxide (Librium).
d. Isocarboxazid (Marplan).
6. A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care?
a. Client will not demonstrate cross addiction.
b. Co-dependent behaviors will be decreased.
c. Excessive CNS stimulation will be reduced.
d. Client's level of consciousness will increase.
7. A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. This client is displaying symptoms of which disorder?
8. A 19-year-old female client with a diagnosis of anorexia nervosa wants to help serve dinner trays to other clients on a psychiatric unit. What action should the nurse take?
a. Encourage the client's self motivation by asking her to pass trays for the rest of the week.
b. Provide an additional challenge by asking the client to help feed the older clients.
c. Suggest another way for this client to participate in the unit's activities.
d. Tell the client that hospital guidelines allow only staff to pass the trays.
9. A female client with depression attends a group and states that she sometimes misses her medication appointments because she feels very anxious about riding the bus. Which statement is the nurse's best response?
a. "Can your case manager take you to your appointments?"
b. "Take your medication for anxiety before you ride the bus."
c. "Let's talk about what happens when you feel very anxious."
d. "What are some ways that you can cope with your anxiety?"
10. A woman brings her 48-year-old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that these behaviors are often associated with which condition?
a. Dissociative disorder.
b. Obsessive-compulsive disorder.
c. Panic disorder.
d. Post-traumatic stress syndrome.
11. At the first meeting of a group of older adults at a day care center for the elderly, the nurse asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, "You tell me, you're the leader." What would be the best response for the nurse to make?
a. "Yes, I am the leader today. Would you like to be the leader tomorrow?"
b. "Yes, I will be leading this group. What would you like to accomplish?"
c. "Yes, I have been assigned to lead this group. I will be here for the next six weeks."
d. "Yes, I am the leader. You seem angry about not being the leader yourself."
12. Over a period of several weeks, one male client participant of a socialization group at a community day care center for the elderly monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in this situation?
a. Talk to the client outside the group about his behavior.
b. Ask the client to give others a chance to talk.
c. Allow the group to handle the problem.
d. Ask the client to join another group.
13. A client in the critical care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveal no significant changes, and the nurse formulates the diagnosis: "Confusion related to ICU psychosis." Which intervention is best to implement based on this client's behavior?
a. Move all machines away from the client's bedside at once.
b. Allay fears by teaching the client about disease etiology.
c. Cluster care to allow for brief rest periods during the day.
d. Encourage visitation by the client's family members.
14. A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates her mannerisms. Which defense mechanism does the nurse recognize in this client?
15. A nurse working on a mental health unit receives a community call from a person who is tearful and states, "I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 to 4 days." The nurse should initiate a referral based on which assessment?
a. Altered thought processes.
b. Moderate levels of anxiety.
c. Inadequate social support.
d. Altered health maintenance.
16. An anxious client expressing a fear of people and open places is admitted to the psychiatric unit. What is the most effective way for the nurse to assist this client?
a. Plan an outing within the first week of admission.
b. Distract her whenever she expresses her discomfort about being with others.
c. Confront her fears and discuss the possible causes of these fears.
d. Accompany her outside for an increasing amount of time each day.
17. Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior?
a. Administer a prescribed PRN anti-anxiety medication.
b. Assist the client to identify stimuli that precipitates the ritualistic activity.
c. Allow time for the ritualistic behavior, then redirect the client to other activities.
d. Teach the client relaxation and thought stopping techniques.
18. The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information would be most useful to the nurse when planning activities for the group?
a. Each resident's length of stay at this nursing home.
b. A brief description of each resident's family life.
c. The age and medication regimen of each group member.
d. The usual activity patterns of each group member.
19. Which ego-defense mechanisms are exhibited by a client with a phobia related to refusal to leave home?
20. A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad. No one can help me." Which response would be best for the nurse to make?
a. "How can I help you? Tell me more about your problems."
b. "Things probably aren't as bad as they seem right now."
c. "Let's talk about what is right with your life."
d. "I hear your misery, but things will get better soon."
21. A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage?
a. He ingested the drug 3 hours prior to admission to the emergency center.
b. The family reports that he took an entire bottle of acetaminophen (Tylenol).
c. He is unresponsive to instructions and is unable to cooperate with emetic therapy.
d. Those with repeated suicide attempts desire punishment to relieve their guilt.
22. A 68-year-old retired secretary is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal, "Assist client to express feelings of guilt." What is true about the goal statement referring to the client's depression?
a. Implementation of this goal should be deferred until further data can be gathered.
b. The depression is most likely age-related and will dissipate once she becomes accustomed to retirement.
c. Depressed clients are often unaware of guilt feelings, and should be encouraged to increase self-awareness.
d. Nursing goals should be approved by the treatment team before they are initiated.
23. The nurse is planning care for a 32-year-old male client diagnosed with HIV infection who has a history of chronic depression. Recently, the client's viral load has begun to increase rather than decrease despite his adherence to the HIV drug regimen. What should the nurse do first while taking the client's history upon admission to the hospital?
a. Determine if the client attends a support group weekly.
b. Hold all anti-depressant medications until further notice.
c. Ask the client if he takes St. John's Wort routinely.
d. Have the client describe any recent changes in mood.
24. The nurse admits a client with depression to the mental health unit. The client reports difficulty concentrating, losing 10 pounds in two weeks, and sleeping 12 hours a day. Which outcome is most important for the client to meet by discharge?
a. Tries to interact with a few peers and staff.
b. Reports feeling better and less depressed.
c. Sits attentively with peers in group therapy.
d. Easily awakens for morning medications.
25. Which diet selection by a depressed client taking tranylcypromine sulfate (Parnate), an MAO inhibitor, indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen?
a. Hamburger, french fries, and chocolate milkshake.
b. Liver and onions, broccoli, and decaffeinated coffee.
c. Pepperoni and cheese pizza, tossed salad, and soda.
d. Roast beef, baked potato with butter, and iced tea.
26. A 72-year-old female is admitted to the psychiatric unit with a medical diagnosis of major depression. Which statement by the client would be of greatest concern to the nurse and would require further assessment?
a. "I think my cat is going to die."
b. "I don't feel like eating this morning."
c. "I just went to my friend's funeral."
d. "Don't you have more important things to do?"
27. A 33-year-old is admitted to a Psychiatric facility with a medical diagnosis of major depression. When the nurse is assigning the client to a room, which roommate is best for this client?
a. A 35-year-old who recently attempted suicide.
b. A manic client who has started lithium carbonate treatment.
c. A client who is bipolar and is pacing the floor telling jokes to everyone.
d. A paranoid client who believes that the staff is trying to poison the food.
28. A client is admitted with a diagnosis of depression. The nurse knows that which characteristic is most indicative of depression?
a. Grandiose ideation.
b. Self-destructive thoughts.
c. Suspiciousness of others.
d. Negative views of self.
29. A 22-year-old female is admitted to the psychiatric unit from the medical unit following a suicide attempt with an overdose of diazepam (Valium). When developing the nursing care plan for this client, what intervention would be most important to include?
a. Assist the client to focus on her strengths.
b. Set limits on the client's self-defacing comments.
c. Remind the client of daily activities in the milieu.
d. Assist the client to identify why she was self-destructive.
30. A female client in an acute care facility has been on antipsychotic medications for the past three days. Her psychotic behaviors have decreased and she has had no adverse reactions. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. What action should the nurse initiate?
a. Place the client on seizure precautions and monitor frequently.
b. Take the client's vital signs and notify the physician immediately.
c. Describe the symptoms to the charge nurse and document them in the client's record.
d. No action is required at this time as these are known side effects of her medications.
31. A 27-year-old female is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. She is demanding and active. What intervention should the nurse include in this client's plan of care?
a. Schedule the client to attend various group activities.
b. Reinforce the client's ability to make her own decisions.
c. Encourage the client to identify feelings of anger.
d. Provide a structured environment with little stimuli.
32. A manic depressive male client on the psychiatric unit becomes loud, and shouts at one of the nurses, "You fat tub of lard, get something done around here." What is the best initial action for the nurse to take?
a. Have the staff escort the client to his room.
b. Tell the client that his behavior will be recorded in his record.
c. Redirect the client by asking him to play card games with peers.
d. Review the medication record for an antipsychotic drug.
33. A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make?
a. "Did you really believe you were Jesus Christ?"
b. "I think you're getting well."
c. "Others have had similar thoughts when under stress."
d. "Why did you think you were Jesus Christ?"
34. A 38-year-old woman is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her room, she refuses to eat and tells the nurse, "I know you are trying to poison me with that food." What response by the nurse is the most therapeutic?
a. "I'll leave your tray here; I am available if you need anything else."
b. "You're not being poisoned. Why do you think someone is trying to poison you?"
c. "No one on this unit has ever died from poisoning. You're safe here."
d. "I will talk to your physician about the possibility of changing your diet."
35. A 35-year-old male client admitted to the psychiatric unit of an acute care hospital tells the nurse that he believes someone is trying to poison him. The client's delusions are most likely related to which factor?
a. Authority issues in childhood.
b. Anger about being hospitalized.
c. Low self-esteem.
d. Phobia of food.
36. A 35-year-old male client who has been hospitalized for two weeks for paranoia complains continuously to the staff that someone is trying to steal his clothing. What is the correct action for the nurse to take based on this client's complaints?
a. Enroll the client in an exercise class to promote self-esteem.
b. Place a lock on the client's closet to deter any theft.
c. Promote extinction of the ideation by ignoring the client.
d. Explain to the client that these suspicions are false.
37. An 86-year-old female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, "Where should I stand for the parade?" Which response is best for the nurse to provide?
a. "Anywhere you want to stand as long as you do not get hurt by those in the parade."
b. "You are confused because of all the activity in the hall. There is no parade."
c. "Let's go back to the activity room and see what is going on in there."
d. "Remember I told you that this is a nursing home and I am your nurse."
38. The nurse is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the physician informed him that he will be moving to a boarding home. What is the most important nursing diagnosis for discharge planning?
a. Ineffective denial related to situational anxiety.
b. Ineffective coping related to inadequate support.
c. Social isolation related to difficult interactions.
d. Self-care deficit related to cognitive impairment.
39. A client who is diagnosed as schizophrenic is admitted to the hospital. The nurse assesses the client's mental status. Which assessment finding is most characteristic of a client with schizophrenia?
a. Mood swings.
b. Extreme sadness.
c. Manipulative behavior.
d. Flat affect.
40. On admission, a highly anxious client is described as delusional. The nurse understands that delusions are most likely to occur with which disorder?
a. Dissociative disorders.
b. Personality disorders.
c. Anxiety disorders.
d. Psychotic disorders.
41. A 25-year-old female client has been particularly restless and the nurse finds her trying to leave the psychiatric unit. She tells the nurse, "Please let me go. I must leave because the secret police are after me." What response is best for the nurse to make?
a. "No one is after you, you're safe here."
b. "You'll feel better after you have rested."
c. "I know you must feel lonely and frightened."
d. "Come with me to your room and I will sit with you."
42. A client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. What action should the nurse take?
a. Notify the physician immediately and force fluids.
b. Prior to giving the next dose, notify the physician of the symptoms.
c. Record the symptoms and continue medication as prescribed.
d. Hold the medication and refuse to administer additional amounts of the drug.
43. A male schizophrenic client, taking fluphenazine deconate (Prolixin deconate), is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation and will return in 18 days. Which statement by the client indicates a need for health teaching?
a. "I am going to have lots of time in the sun."
b. "While I am on vacation, I will not eat or drink anything that contains alcohol."
c. "I will notify the doctor if I have a sore throat or flu-like symptoms."
d. "I will continue to take my benzotropine mesylate (Congentin) every day."
44. An adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate) because of medication noncompliance. What is important to teach the client and family about this change in medication regimen?
a. Long-acting medication is more effective than daily medication.
b. A client with substance abuse must not take any oral medications.
c. There will continue to be a risk of alcohol and drug interaction.
d. Support groups are only helpful for substance abuse treatment.
45. The nurse develops a plan of care for a client with symptoms of paranoia and psychosis. The priority nursing diagnosis is "Impaired social interactions related to inability to trust." Which intervention is most important for the nurse to implement?
a. Greet the client by first name during each social interaction.
b. Determine if the client is experiencing auditory hallucinations.
c. Introduce the client to peers on the unit as soon as possible.
d. Assign the client to a group about developing social skills.
46. The nurse is conducting discharge teaching for a client who has schizophrenia and plans to live in a group home. Which statement is most indicative of the need for careful follow-up after discharge?
a. "Crickets are a good source of protein."
b. "I have not heard any voices for a week."
c. "Only my belief in God can help me."
d. "Sometimes I have a hard time sitting still."
47. An 8-year-old child is seen in the clinic with a green vaginal discharge. What action is most important for the nurse to implement?
a. Assess the child's blood pressure.
b. Counsel the child to wear cotton underwear.
c. Report as suspected child abuse.
d. Determine if the child takes bubble baths.
48. Clients are preparing to leave the mental health unit for an outdoor smoke break. A client on constant observation cannot leave and becomes agitated and demands to smoke a cigarette. What action should the nurse take first?
a. Remind the client to wear the nicoderm (nicotine) patch.
b. Determine if the client still needs constant observation.
c. Encourage the client to attend the smoking cessation group.
d. Explain that clients on constant observation cannot smoke.
49. The nurse collaborates with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours of hospital admission?
a. Assign the client a case manager.
b. Document activities.
c. Maintain safety in the client's milieu.
d. Identify current psychosocial stresses.
50. The charge nurse collaborates with the nursing staff members about the plan of care for a client who is depressed. What is the most important intervention to implement during the first 48 hours after the client's admission to the unit?
a. Monitor appetite and observe intake at meals.
b. Maintain safety in the client's milieu.
c. Provide ongoing, supportive contact.
d. Encourage participation in activities.
Goes over Mood, Anxiety, Dissociative, and Somatoform disorders in surface detail. Giving a short description of what each means.
NURS 6550 Acute Care Study Guide for Midterm Walden University.docx
NURS 6550 Acute Care Study Guide for Midterm Walden U
NURS 6550 Acute Care Study Guide for Midterm
• Evaluate patients with psychosocial health conditions
• Develop differential diagnoses for patients with psychosocial health conditions
• Develop treatment plans for patients with psychosocial health conditions
Generalized anxiety disorder diagnosis criteria- Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
B. The person finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one item is required in children.
(1) restlessness or feeling keyed up or on edge
(2) being easily fatigued
(3) difficulty concentrating or mind going blank
(5) muscle tension
(6) sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
Primary neurotransmitter in PTSD- Due to the traumatic stress of PTSD victims, the neurotransmitters that fuel the sympathetic versus parasympathetic system get out of balance. As a Yale University journal review states, “It has been suggested that alterations in NE [norepinephrine], E [epinephrine], and 5-HT [5HTP] may have relevance for symptoms commonly seen in survivors with PTSD
* PTSD diagnosis and treatment-assessing history of exposure to a perceived or actual life threatening event, serious injury or sexual violence, symptoms lasting more than 1 month. Disturbance causes clinically significant distress or impairment in functioning
H) The disturbance is not attributable to the physiological effects of a substance or other medical condition
DSM-5 recognizes a “with dissociative symptom” specifier when the PTSD symptoms are accompanied by persistent or recurrent depersonalization or derealization.
The specifier “with delayed expression” should be included if the full criteria for PTSD are not met for more than 6 months following the trauma.
The traumatic event is persistently re-experienced:
• Intrusive thoughts of the traumatic event
• Marked emotional distress when exposed to traumatic reminders
• Strong physiologic reaction when exposed to traumatic reminders
Treatment psychotherapy (cognitive processing, prolonged exposure therapy, eye-movement desensitizing) . SSRIs (sertraline, paroxetine) clonidine 0.1mg at bed time, prazosin 2-10mg for nightmare, antiseizure meds for anger management (carbamazepine 400-800mg daily), clonazepam 1-4mg daily for anxiety, Trazodone 25-100mg for sleep.
Treatment of acute panic attacks- What are the medications for initial/first line therapy- SL 0.5-1 mg alprazolam, clonazepam 0.5-1mg, antidepressants, SSRIs (sertraline 25mg/day for 1 week, then 50mg)
Inpatient treatment of depression- ECT
o What are the therapies for patient’s that won’t eat, take meds, etc.
When is serotonin norepinephrine reuptake inhibitor indicated, when is it contraindicated? For pain neuropathy/fibromyalgia
Venlafaxine dosing, when is follow up? What are you monitoring? - Blood pressure monitoring, arrhythmias DOSE is 150-225 mg daily. Patients should be cautioned about the concomitant use of Venlafaxine tabletsand NSAIDs, aspirin, warfarin, or other drugs that affect coagulation since combined use of psychotropic drugs that interfere with serotonin reuptake and these agents has been associated with an increased risk of bleeding (see PRECAUTIONS,Abnormal Bleeding).
Usual Adult Dose for Anxiety
Initial dose: 75 mg orally once a day
Maintenance dose: May increase in daily increments of 75 mg orally at intervals of no less than 4 days
Maximum dose: 225 mg orally per day
Usual Adult Dose for Panic Disorder
Initial dose: 37.5 mg orally once a day
Maintenance dose: May increase dose in daily increments of 75 mg orally at intervals of no less than 7 days
Maximum dose: 225 mg orally per day
Usual Adult Dose for Depression
Initial dose: 37.5 mg orally twice a day or 25 mg orally 3 times a day
Maintenance dose: May increase in daily increments of up to 75 mg orally at intervals of no less than 4 days
Maximum dose: (moderately depressed outpatients): 225 mg orally per day
Maximum dose (severely depressed inpatients): 375 mg orally per day
-Daily dosage may be divided in 2 or 3 doses/day
Endogenous depression pathophysiology is best described as?
Endogenous depression. Endogenous depression (melancholia) is an atypical sub-class of the mood disorder, major depressive disorder (clinical depression). Endogenous depression occurs due to the presence of an internal (cognitive, biological) stressor instead of an external (social, environmental) stressor. No apparent outside cause.
Exogenous is caused by something (stress, some event)
Differences between panic attacks and panic disorder? Panic attacks are recurrent, unpredicted episodes of intense surges of anxiety accompanied by marked physical manifestations. Panic Disorder
Someone with generalized anxiety disorder (GAD) has chronic anxiety, and a tendency to become over-anxious about issues which would not normally cause concern. Panic disorder is characterized by repeated episodes of panic attacks, in which the individual is overcome by feelings of fear and dread.
What are Major Depressive disorder symptoms?- physical & cognitive symptoms, loss of interest and pleasure(anhedonia) withdrawal from activities and guilt, poor concentration, worthlessness, fatigue
Identify the primary neurotransmitter in PTSD
• PTSD diagnosis and treatment, meds (families/common meds)?
Familiarize yourself with the side effects of Lithium- GI, tremors-treat with propranolol 20-60mg a day, weakness, somnolence, polyuria (reduced renal response ADH) , polydipsia (increased plasma renin concentration), thyroid, EKG changes, long term effects cogwheel rigidity, affect
Common adverse effects of atypical antipsychotics- anticholinergic side effects dry mouth which can cause increases caloric liquid intake (wt gain & hyponatremia) blurred vision, urinary retention, delayed gastric emptying, esophageal reflux, ileus, delirium, acute glaucoma, sexual disturbances, and orthostatic hypotension, EKG changes prolonged QT
Mental status changes in elderly… how do you evaluate?
Mental status changes related to UTI in elderly
Assessment of Delirium in geriatric patients- Acute onset, fluctuating course, deficits in attention not memory.
Elders with dementia and driving – there is no gold standard assessment, consider the severity of the dementia ( severe should not drive), consider comorbidities and medications, ability to do IADLS, , may need to be assessed by a driver rehab specialist.
Short Confusion Assessment Method (Short CAM): what things are assessed? Acute onset and fluctuating course, inattention and either disorganized thinking or ALOC.
Types of dementia, know differences?
Alzheimer\\\'s disease- Alzheimer\\\'s disease
Most common type of dementia; accounts for an estimated 60 to 80 percent of cases.
Symptoms: Difficulty remembering recent conversations, names or events is often an early clinical symptom; apathy and depression are also often early symptoms. Later symptoms include impaired communication, poor judgment, disorientation, confusion, behavior changes and difficulty speaking, swallowing and walking.
Revised guidelines for diagnosing Alzheimer’s were published in 2011 recommending that Alzheimer’s be considered a slowly progressive brain disease that begins well before symptoms emerge.
Brain changes: Hallmark abnormalities are deposits of the protein fragment beta-amyloid (plaques) and twisted strands of the protein tau (tangles) as well as evidence of nerve cell damage and death in the brain
Vascular dementia- Vascular dementia
Previously known as multi-infarct or post-stroke dementia, vascular dementia is less common as a sole cause of dementia than Alzheimer’s, accounting for about 10 percent of dementia cases.
Symptoms: Impaired judgment or ability to make decisions, plan or organize is more likely to be the initial symptom, as opposed to the memory loss often associated with the initial symptoms of Alzheimer\\\'s. Occurs from blood vessel blockage or damage leading to infarcts (strokes) or bleeding in the brain. The location, number and size of the brain injury determines how the individual\\\'s thinking and physical functioning are affected.
Brain changes: Brain imaging can often detect blood vessel problems implicated in vascular dementia. In the past, evidence for vascular dementia was used to exclude a diagnosis of Alzheimer\\\'s disease (and vice versa). That practice is no longer considered consistent with pathologic evidence, which shows that the brain changes of several types of dementia can be present simultaneously. When any two or more types of dementia are present at the same time, the individual is considered to have mixed dementia
Dementia with Lewy bodies (DLB)- Dementia with Lewy bodies (DLB) back to top
Symptoms: People with dementia with Lewy bodies often have memory loss and thinking problems common in Alzheimer\\\'s, but are more likely than people with Alzheimer\\\'s to have initial or early symptoms such as sleep disturbances, well-formed visual hallucinations, and slowness, gait imbalance or other parkinsonian movement features.
Brain changes: Lewy bodies are abnormal aggregations (or clumps) of the protein alpha-synuclein. When they develop in a part of the brain called the cortex, dementia can result. Alpha-synuclein also aggregates in the brains of people with Parkinson\\\'s disease, but the aggregates may appear in a pattern that is different from dementia with Lewy bodies.
The brain changes of dementia with Lewy bodies alone can cause dementia, or they can be present at the same time as the brain changes of Alzheimer\\\'s disease and/or vascular dementia, with each abnormality contributing to the development of dementia. When this happens, the individual is said to have mixed dementia.
Mixed dementia- Mixed dementia
In mixed dementia abnormalities linked to more than one cause of dementia occur simultaneously in the brain. Recent studies suggest that mixed dementia is more common than previously thought.
Brain changes: Characterized by the hallmark abnormalities of more than one cause of dementia —most commonly, Alzheimer\\\'s and vascular dementia, but also other types, such as dementia with Lewy bodies.
Parkinson\\\'s disease- Parkinson\\\'s disease
As Parkinson\\\'s disease progresses, it often results in a progressive dementia similar to dementia with Lewy bodies or Alzheimer\\\'s.
Symptoms: Problems with movement are common symptoms of the disease. If dementia develops, symptoms are often similar to dementia with Lewy bodies.
Brain changes: Alpha-synuclein clumps are likely to begin in an area deep in the brain called the substantia nigra. These clumps are thought to cause degeneration of the nerve cells that produce dopamine.
Frontotemporal dementia- Frontotemporal dementia
Includes dementias such as behavioral variant FTD (bvFTD), primary progressive aphasia, Pick\\\'s disease, corticobasal degeneration and progressive supranuclear palsy.
Symptoms: Typical symptoms include changes in personality and behavior and difficulty with language. Nerve cells in the front and side regions of the brain are especially affected.
Brain changes: No distinguishing microscopic abnormality is linked to all cases. People with FTD generally develop symptoms at a younger age (at about age 60) and survive for fewer years than those with Alzheimer\\\'s.
Creutzfeldt-Jakob disease- CJD is the most common human form of a group of rare, fatal brain disorders affecting people and certain other mammals. Variant CJD (“mad cow disease”) occurs in cattle, and has been transmitted to people under certain circumstances.
Symptoms: Rapidly fatal disorder that impairs memory and coordination and causes behavior changes.
Brain changes: Results from misfolded prion protein that causes a \\\"domino effect\\\" in which prion protein throughout the brain misfolds and thus malfunctions.
Normal pressure hydrocephalus-Normal pressure hydrocephalus
Symptoms: Symptoms include difficulty walking, memory loss and inability to control urination.
Brain changes: Caused by the buildup of fluid in the brain. Can sometimes be corrected with surgical installation of a shunt in the brain to drain excess fluid.
Huntington\\\'s Disease back to top
Huntington’s disease is a progressive brain disorder caused by a single defective gene on chromosome 4.
Symptoms: Include abnormal involuntary movements, a severe decline in thinking and reasoning skills, and irritability, depression and other mood changes.
Brain changes: The gene defect causes abnormalities in a brain protein that, over time, lead to worsening symptoms
Wernicke-Korsakoff Syndromeback to top
Korsakoff syndrome is a chronic memory disorder caused by severe deficiency of thiamine (vitamin B-1). The most common cause is alcohol misuse.
Symptoms: Memory problems may be strikingly severe while other thinking and social skills seem relatively unaffected.
Brain changes: Thiamine helps brain cells produce energy from sugar. When thiamine levels fall too low, brain cells cannot generate enough energy to function properly
Aricept and dosing and patient teaching? Donepezil 5 mg PO once daily max dose 10mg daily, side effects diarrhea, nausea, anorexia, wt loss, syncopal. D/C med if no benefits or having side effects, or financial burdens, evaluate after 2 months of highest dose
Most important fact about this drug
To maintain any improvement, Aricept must be taken regularly. If the drug is stopped, its benefits will soon be lost. Patience is in order when starting the drug. It can take up to 3 weeks for any positive effects to appear.
How should you take this medication?
Aricept should be taken once a day just before bedtime. Be sure it\\\'s taken every day. If Aricept is not taken regularly, it won\\\'t work. It can be taken with or without food.
If you miss a dose...
Make it up as soon as you remember. If it is almost time for the next dose, skip the one that was missed and go back to the regular schedule. Never double the dose.
Management of disinhibition in elderly-
• Physical findings when death is imminent- dyspnea, nausea/vomiting. Pain, constipation, fatigue, delirium/agitation, Coolness. Hands, arms, feet, and legs may be increasingly cool to the touch. ...Confusion. ... Sleeping. ... Incontinence. ... Restlessness. ... Congestion. ... Urine decrease. ... Fluid and food decrease, Little appetite and thirst. Fewer and smaller bowel movements and less pee, More pain, Changes in blood pressure, breathing, and heart rate.
Limits of pain medication on dying patient- use long acting opioids around the clock and short acting opioids for breakthrough pain , do not undertreat pain in the dying pt (in rare cases palliative sedation may be needed, use of versed or phenobarbital IV with monitoring)
Theories about successful aging…familiarize yourself with them- A person was deemed to have successfully aged if the person (1) lived free of disability or disease; (2) had high cognitive and physical abilities; and (3) was interacting with others in meaningful ways
Reducing risk factors for disease/disability • Genetic risks decline with age; lifestyle factors determine risk • Risk factors can be reduced/modified (e.g. weight loss program effect on cardiovascular disease) • Increased within-person variability is predictor of mortality (better than just their mean level of performance) • Maximizing cognitive and physical function • Predictors of cognitive function: education, strenuous activity around home, peak pulmonary flow rate, self-efficacy • Education: due to direct beneficial effect or leads to life-long learning? • Cognitive function can be enhanced; plasticity persists in older age • Continuing engagement with life • Social relations: Being part of social network determines longevity, esp for men • Socio-emotional (affection) vs instrumental (direct assistance) support • Productive activity predictors: functional capacity, education, and self-efficacy • Response to stress • More ‘stressful life events’ and ‘daily hassles’; need resilience to recover and meet criteria for successful aging
• Activity theory
• Continuity theory
• Disengagement theory
The activity theory occurs when individuals engage in a full day of activities and maintain a level of productivity to age successfully. The activity theory basically says: the more you do, the better you will age. It makes a certain kind of sense, too. People who remain active and engaged tend to be happier, healthier, and more in touch with what is going on around them. Same goes for people of any age.
Often, the activity theory is dismissed to some degree because it falls a little flat. It isn\\\'t sufficient to just be busy, like the definition states. You can\\\'t wake up every day and do the same thing, like riding a stationary bike, and expect to age well. This theory was taken and used by many program designers for the elderly, who filled older folks\\\' schedules with busy work and required them to complete tasks. A heightened level of activity is needed, but it needs to be engaging and fulfilling, rather than just busy work.
The theory also fails to consider maintenance of one\\\'s mid-life or changes that are made when entering retired or older life. If I was a high-powered, high-stress executive and I retire and go into pottery making, am I going to age successfully? Not likely, particularly if I enjoyed my job as an executive. Maybe what is needed is another theory that looks at the lifespan instead of just older age.
The continuity theory states that individuals who age successfully continue habits, preferences, lifestyle, and relationships through midlife and later. Again, this theory makes a certain kind of intuitive sense. People who are doing well in midlife, who are happy, healthy, and just plain dandy should carry over the habits and ideals that made them that way. Basically, good stuff should be continued because it\\\'s good stuff!
An easy way of thinking about how the continuity theory can demonstrate successful aging is by considering your own life.
The disengagement theory of aging states that \\\"aging is an inevitable, mutual withdrawal or disengagement, resulting in decreased interaction between the aging person and others in the social system he belongs to\\\". The theory claims that it is natural and acceptable for older adults to withdraw from society.
Psychological abuse of elders
Death and the anxiety related to it, who’s at risk?
Age and suicide risk in the different age groups?
Geriatric Depression Screen-
Geriatric Depression Scale: Short Form
Choose the best answer for how you have felt over the past week: 1. Are you basically satisfied with your life? YES / NO 2. Have you dropped many of your activities and interests? YES / NO 3. Do you feel that your life is empty? YES / NO 4. Do you often get bored? YES / NO 5. Are you in good spirits most of the time? YES / NO 6. Are you afraid that something bad is going to happen to you? YES / NO 7. Do you feel happy most of the time? YES / NO 8. Do you often feel helpless? YES / NO 9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO 10. Do you feel you have more problems with memory than most? YES / NO 11. Do you think it is wonderful to be alive now? YES / NO 12. Do you feel pretty worthless the way you are now? YES / NO 13. Do you feel full of energy? YES / NO 14. Do you feel that your situation is hopeless? YES / NO 15. Do you think that most people are better off than you are? YES / NO
Answers in bold indicate depression. Score 1 point for each bolded answer.
A score > 5 points is suggestive of depression. A score ≥ 10 points is almost always indicative of depression. A score > 5 points should warrant a follow-up comprehensive assessment.
Geriatric Depression Scale
The Geriatric Depression Scale (GDS) was specifically developed for use in geriatric populations, originally as a 30-item scale. It was modified a 15-item scale, which has been widely used. The GDS was later reduced to 5 items, so as to be better received by elderly patients. The questions elicit only “yes” or “no” responses, making comprehension easier compared with multiple-choice answers.
The 5-item scale has a sensitivity of 94%, specificity of 81%, and demonstrated a significant agreement in the clinical diagnosis of depression with the 15-item scale. The 5-item scale is scored by 1 point for a “no” answer on the first question or a “yes” answer for the remaining questions. A score of greater than or equal to 2 is a positive screen for depression
Which of the following is not an indication for use of a serotonin-norepinephrine reuptake inhibitor?- Unresponsiveness to an SSRI
Lucy Garcia is a 42-year-old Hispanic female with a 20-plus-year history of depression. She is currently hospitalized for treatment of progressive, acute-on-chronic depressive symptoms, including refusal to get out of bed and inattentiveness to personal hygiene.------Electroconvulsive treatments
Which of the following are risk factors for obesity? (Select all that apply.----- African American and Hispanic youth are at increased risk for childhood and adolescent obesity, Skipping breakfast
Frequent takeout/fast-food meals, Consumption of sugar sweetened beverages
How should a physician assess the risk for suicide in a depressed adolescent? (Select all that apply.)
By asking family members whether they feel that the patient is at risk for suicide
By establishing a no-suicide contract with depressed adolescents
Why must a physician assess the risk for suicide in a depressed adolescent? All suicide gestures should be taken seriously
WEEK 3 ENT
Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F.A. Davis Company.
• Section 5, “Head: Eyes, Ears, Nose, and Mouth”
o Chapter 68, “Audiometry Testing”- C/O tinnitus, unexplained behavior changes in geriatrics, contraindications (cerumen obstruction, otitis externa) pull the pinna up and back, normal -10-26 dB, mild 20-40 dB, mod. 56-70 dB, profound 91 dB
o Chapter 70, “Tympanometry” – test mobility of tympanic membrane, middle ear pressure, and volume of the external canal. Used to measure otitis media resolution, serous otitis media, presence of eustachian tube dysfunction problems and screen for developemental delays. The tympanometer measures the \\\"admittance\\\" or \\\"compliance\\\" of the tympanic membrane while different pressures are being applied to the external ear canal.TM is measured in cubic centimeters, and the pressure in the ear canal is measured in decapascals (daPa). If the middle ear space is filled with fluid, most of the sound is reflected back to the probe from the stiff tympanic membrane. If the middle ear space is filled with air, and the ossicles are intact, energy is absorbed by the tympanic membrane, ossicles, and inner ear structures. The tracing will read \\\"normal\\\". If there is disruption of the ossicles, or if a portion of the TM is flaccid, a large amount of energy will be absorbed into the TM and the tracing will display an abnormally peaked compliance.
Chapter 71, “Visual Function: Evaluation (Snellen, Illiterate E) Procedures—Eyes”
o Chapter 76, “Eyebrow Laceration Repair”-may consider suturing beyond the 6 hr postlac time d/t cosmetic reasons, above and below eyebrow may be close d with steri stripes if less than 0.25 cm in length (poor cosmetic healing), contraindications (involves intramarginal lid of the eye, greater than 12 hrs old, global injury or orbit fx) suture, appy topical antibiotic ointment, light pressure dressing remove in 24 hrs, remove in 3-5 days, no PO antibiotics can use topical antibiotics) Tylenol for pain
o Chapter 77, “Eyelid Eversion Procedures: Ears/Nose” pt look down use cotton tip applicator to flip eye lid up, then have pt look up to return to normal
o Chapter 79, “Cerumen Impaction Removal: Irrigation of the Ear and Curette Technique” Curette technique for easily visualized wax, irrigation (mix hydrogen peroxide and H2O room temp (cold or to warm can cause vertigo) don’t direct toward tympanic membrane , after removal dry ear canal with alcohol applied to a cotton applicator, home remadies instill 2 drops of warmed mineral or glycerin or over counter agents 4x a day for 4 days, return to office
o Chapter 80, “Ear Piercing”
o Chapter 88, “Tooth Avulsion and Fracture”
Papadakis, M. A., McPhee, S. J., & Rabow, M. W. (2018). Current medical diagnosis & treatment (57th ed.). New York, NY: McGraw Hill.
• Chapter 7, “Disorders of the Eyes & Lids” (pp. 170-204)
• Chapter 8, “Ear, Nose, & Throat Disorders” (pp. 205-245)
Weber, E. C., Vilensky, J. A., & Fog, A. M. (2013). Practical radiology: A symptom-based approach. Philadelphia, PA: F.A. Davis Company.
• Chapter 5, “EENT Imaging” (pp. 105–123)
• Cornea: clear front window of the eye that transmits and focuses light into the eye.
• Iris: colored part of the eye that helps regulate the amount of light that enters
• Posterior chamber region behind the iris
• Anterior chamber region between the cornea and iris
• Pupil: dark aperture in the iris that determines how much light is let into the eye
• Lens: transparent structure inside the eye that focuses light rays onto the retina
• Retina: nerve layer that lines the back of the eye, senses light, and creates electrical impulses that travel through the optic nerve to the brain
• Macula: small central area in the retina that contains special light-sensitive cells and allows us to see fine details clearly
• Optic nerve: connects the eye to the brain and carries the electrical impulses formed by the retina to the visual cortex of the brain
• Vitreous: clear, jelly-like substance that fills the middle of the eye
Eye pressure is measured in millimeters of mercury (mm Hg). Normal eye pressure ranges from 12-22 mm Hg, and eye pressure of greater than 22 mm Hg is considered higher than normal. When the IOP is higher than normal but the person does not show signs of glaucoma, this is referred to as ocular hypertension.
Eye pain from medications- Ophthalmic solutions risk for contamination are preservative free solutions like tetracaine, proparacaine, fluorescein. Most dangerous is fluorescein D/T contamination with P aeruginosa which can rapidly destroy the eye. Store preservative -free in the refrig, trash after 1 week of opening. Eye trauma -use freshly open bottles or single use products. Long term topical eye therapy patient may develop hypersensitivity reaction to active ingredients or preservative. To avoid systemic reaction use 1-2 drops at a time and few minutes of nasolacrimal occlusion or eyelid closure. Preventative free for glaucoma treatment and contact lens solutions
* Cataract Familiarize yourself with Cataracts, presentation? TRX?- REFER TO OPTHO WHEN VISION LOSS EFFECT ACTIVITIES OF DAILY LIVING/ Complications Serious complications of cataract surgery include retinal detachment and endophthalmitis
You develop them when protein builds up in the lens of your eye and makes it cloudy. This keeps light from passing through clearly. It can cause you to lose some of your eyesight decreased visual acuity, gradual progressive blurred vision, no pain or redness, lens opacities may be grossly visible. They are opacities of the crystalline lens and ae usually bilateral, leading cause of blindness, congenital, (owing to intrauterine infections, rubella/CMV, traumatic, secondary to disease (diabetes, myotonic dystrophy, atopic dermatitis, corticosteroid use, uveitis, radiation, statin drugs, smoking increase the risk, vitamins/antioxidants may prevent. Complaints of glare with bright light or night driving, cataract can be seen with a dilated pupil,
Risk factors such as UVB exposure and smoking can be addressed. Although no means of preventing cataracts has been scientifically proven, wearing sunglasses that counteract ultraviolet light may slow their development. While adequate intake of antioxidants (such as vitamins A, C, and E) has been thought to protect against the risk of cataracts, clinical trials have shown no benefit from supplements; though evidence is mixed, but weakly positive, for a potential protective effect of the nutrients lutein and zeaxanthin. Statin use is somewhat associated with a lower risk of nuclear sclerotic cataracts.[
TREATMENT - Cataract removal can be performed at any stage and no longer requires ripening of the lens. Surgery is usually \\\'outpatient\\\' and performed using local anesthesia. About 9 of 10 patients can achieve a corrected vision of 20/40 or better after surgery.
Several recent evaluations found that cataract surgery can meet expectations only when significant functional impairment due to cataracts exists before surgery. Visual function estimates such as VF-14 have been found to give more realistic estimates than visual acuity testing alone. In some developed countries, a trend to overuse cataract surgery has been noted, which may lead to disappointing results.
Phacoemulsification is the most widely used cataract surgery in the developed world. This procedure uses ultrasonic energy to emulsify the cataract lens. Phacoemulsification typically comprises six steps:
• Anaesthetic – The eye is numbed with either a subtenon injection around the eye (see: retrobulbar block) or topical anesthetic eye drops. The former also provides paralysis of the eye muscles.
• Corneal incision – Two cuts are made at the margin of the clear cornea to allow insertion of instruments into the eye.
• Capsulorhexis – A needle or small pair of forceps is used to create a circular hole in the capsule in which the lens sits.
• Phacoemulsification – A handheld ultrasonic probe is used to break up and emulsify the lens into liquid using the energy of ultrasound waves. The resulting \\\'emulsion\\\' is sucked away.
• Irrigation and aspiration – The cortex, which is the soft outer layer of the cataract, is aspirated or sucked away. Fluid removed is continually replaced with a saline solution to prevent collapse of the structure of the anterior chamber (the front part of the eye).
• Lens insertion – A plastic, foldable lens is inserted into the capsular bag that formerly contained the natural lens. Some surgeons also inject an antibiotic into the eye to reduce the risk of infection. The final step is to inject salt water into the corneal wounds to cause the area to swell and seal the incision.
Extracapsular cataract extraction (ECCE) consists of removing the lens manually, but leaving the majority of the capsule intact. The lens is expressed through a 10- to 12-mm incision which is closed with sutures at the end of surgery. ECCE is less frequently performed than phacoemulsification, but can be useful when dealing with very hard cataracts or other situations where emulsification is problematic. Manual small incision cataract surgery (MSICS) has evolved from ECCE. In MSICS, the lens is removed through a self-sealing scleral tunnel wound in the sclera which, ideally, is watertight and does not require suturing. Although \\\"small\\\", the incision is still markedly larger than the portal in phacoemulsion. This surgery is increasingly popular in the developing world where access to phacoemulsification is still limited.
Intracapsular cataract extraction (ICCE) is rarely performed. The lens and surrounding capsule are removed in one piece through a large incision while pressure is applied to the vitreous membrane. The surgery has a high rate of complications.
The postoperative recovery period (after removing the cataract) is usually short. The patient is usually ambulatory on the day of surgery, but is advised to move cautiously and avoid straining or heavy lifting for about a month. The eye is usually patched on the day of surgery and use of an eye shield at night is often suggested for several days after surgery.
In all types of surgery, the cataractous lens is removed and replaced with an artificial lens, known as an intraocular lens, which stays in the eye permanently. Intraocular lenses are usually monofocal, correcting for either distance or near vision. Multifocal lenses may be implanted to improve near and distance vision simultaneously, but these lenses may increase the chance of unsatisfactory vision
Herpes zoster- affects the trigeminal nerve, malaise, fever, periorbital burning and itching
Hordeolum-staphylococcal abscess red/tender/swollen area upper or lower eye lid, warm compresses/ bacitracin or erthy ointment, not better in 48 hrs incision may need to be done
Chalazion-granulomatous inflammation of the Meibomian gland, hard/nontender swelling on the upper and lower lids
Blepharitis-chronic bilateral inflammatory condition of the lid margins
Entropion-inward turning of lower lid
Ectropion-outward turning of the lower lid
Vitreous hemorrhage- sudden visual loss, floaters, bleeding within the eye, caused by retinal tear, diabetic retinopathy, retinal vein occlusion, retinal vasculitis
* Dacrocystitis- an infection of the lacrimal sac, due to congenital or acquired obstruction of the nasolacrimal system, acute or chronic in peds and age over 40, unilateral, staphylococcus aureus and streptococci in acute dacryocystitis and staphylococcus epidermidis, streptococci, or gram-negative bacilli in chronic dacrocystitis. ACUTE is characterized by pain, swelling, tenderness, and redness in the tear sac area, may have purulent material, systemic antibiotics, surgery. CHRONIC tearing and discharge are the primary signs (mucus and pus), antibiotics, relive the obstruction (surgery of the lacrimal sac/formation of fistula into the nasal cavity, nasolacrimal intubation or balloon). Congenital usually resolve spontaneously.
• What is acute angle glaucoma? – (ACUTE ANGLE-CLOSURE CRISIS ESSENTIAL S AGE GROUP/ FARSIGHTED/RAPID ONSET OF SEVER PAIN/PROFOUND VISUAL LOSS/HALOS AROUND LIGHTS/RED EYE/ CLOUDY CORNEA/DIALATED PUPIL/ HARD ON PALPATION/ MAY HAVE NAUSEA & ABD PAIN. Visual field and decreased visual acuity, PRIMARY -closure of the preexisting narrow anterior chamber angle, precipitated by pupil dilatation (can occur from sitting in a dark theater, stress, meds anticholinergics, bronchodilators, atropine, antidepressants, antispasmodics, nasal decongestants) common in Inuits and Asians. SECONDARY does not require a preexisting narrow angel, occur in anterior uveitis or dislocation of the lens due to drug, SYMPTOMS SAME AS PRIMARY difference is in management, associated with hemodialysis, TREATMENT IS REDUCTION OF INTRAOCULAR PRESSURE WITH A SINGLE 500 MG iv DOSE OF ACETAZOLAMIDE, FOLLOWED BY 250 MG ORALLY 4 X DAY WITH TOPICAL ONITMENT/OSMOTIC DIURETICS SUCH AS ORAL GLYCERIN AND IV UREA OR MANNITOL ALL DOSED AT 1-2 G/KG MAYBE USED IF ACETAZOLAMIDE DOESNOT WORK
ONCE PRESSURE DECREASES FOR PRIMARY ACUTE ANGLE GLACOMA TOPICAL 4% PILOCARPINE 1 DROP EVERY 15 MINUTES FOR 1 HOUR THEN 4 TIMES A DAY/ FAILURE OF TREATMENT MAY NEED SURGICAL CORNEAL INDENTATION LASER TREATMENT
ALL PATIENTS SHOULD UNDERGO PROPHYLATIC LASER PERIPHERAL IRIDOTOMY TO THE UNAFFECTED EYE. SECONDARY ADDED TX IS DETERMINED BY THE CAUSE
IF NOT TREATED IN 2-5 DAYS PERMANET VISUAL LOSS (MUST REF EMERGENTLY TO AN OPTHALMOLOGIST)
• Chronic uveitis medication management- INTRAOCULAR INFLAMMATION, PRIMARYLY IMMUNOLOGIC/DISORDERS ASSOCIATED ARE ANKYLOSING SPONDYLITID, REACTIVE ARTHRITIS, PSORIASIS/ UC AND CROHNS (ALL THES ARE HLA-B27) HERPES SIMPLEX/ZOSTER CAN CAUSE NONGRANULOMATUS ANTERIOR UVETITIS, vision blurred, mod. Pain, cornea clear, pupil size small, pupil response poor, intraocular pressure usually normal can be elevated, no organisms/ TREATMENT FOR ANTERIOR UVETITIS TOPICAL STEROIDS,DILATATION OF THE PUPIL IS IMPORTANT TO RELIEVE DISCOMFORT, POSTERIOR -TREATMENT SYSTEMIC PERIOCULAR OR INTRAVITREAL CORTICOSTERIODS (AZATHIOPRINE, CYSLOSPORINE, MYCOPHENOLATE, METHOTREXATE, TACROLIMUS, SIROLIMUS (BIOLOGIC THERAPHY/INTRACULAR INJECTION) INFECTIOUSE CAUSE USE ANTIBIOTICS NO NEED FOR PUPIL DILITATION, POSTERIOR IS WORSE THAN ANTERIOR/REFER URGENTLY TO OPTHO, ERGENT WITH VISUAL LOSS, ADMIT FOR SEVERE UVEITIS AND THOSE NEEDING IV THERAPHY
• Gonococcal conjunctivitis presentation and medication management-contact from infected genital secretions, copious discharge, OPTHOMOLOGY EMERGENCY, stained smear and culture of discharge, 1 gram of IM ceftriaxone, topical may be added (bacitracin/ erythromycin)
• Trachoma (chlamydial Kertoconjuctivitis -most common infections to cause blindness
• Dry eye (Keratoconjunctivitis Sicca) loss of aqueous component of tears
• Allergic conjunctivitis- itchy, tearing, redness, stringy discharge, occasional photophobia and vision loss
• Viral, allergic, bacterial conjunctivitis: CORNEA CLEAR, PUPIL NORMAL, LIGHT RESPONSE NORMAL, INTRAOCULAR PRESSURE NORMAL know presentations and trx- Conjunctivitis most common eye disease, acute / chronic. VIRAL – adenovirus is the most common cause
Bilaterally/copious discharge/FB sensation to eye/follicular conjunctivitis. Adenovirus type 8,19, 37 causes keratoconjunctivitis results in vision loss, lasts about 2 weeks. Adenovirus type 3,4,7 and 11 is associated with pharyngitis, fever, malaise and preauricular adenopathy (pharyngoconjunctival fever) last 10 days. VIRAL- due to herpes, unilateral, lid vesicles, and enterovirus 70 or coxsackievirus A24 (acute hemorrhage) No treatment for viral cold compresses/ topical sulfonamides to prevent secondary infections, Viral from HERPES use topical ganciclovir 0.15% gel and or oral acyclovir 3% 5x day. BACTERIAL- cause staph, MRSA, S pneumoniae, haemophilus, , copious purulent discharge, severe cases obtain culture to r/o gonococcal, last 10-14 days, topical sulfonamide or oral antibiotics.
Macular degeneration presentation and S&S, trx - is a common eye condition and a leading cause of vision loss among people age 50 and older. It causes damage to the macula, a small spot near the center of the retina and the part of the eye needed for sharp, central vision, which lets us see objects that are straight ahead.
In some people, AMD advances so slowly that vision loss does not occur for a long time. In others, the disease progresses faster and may lead to a loss of vision in one or both eyes. As AMD progresses, a blurred area near the center of vision is a common symptom. Over time, the blurred area may grow larger or you may develop blank spots in your central vision. Objects also may not appear to be as bright as they used to be.
AMD by itself does not lead to complete blindness, with no ability to see. However, the loss of central vision in AMD can interfere with simple everyday activities, such as the ability to see faces, drive, read, write, or do close work, such as cooking or fixing things around the house.
The macula is made up of millions of light-sensing cells that provide sharp, central vision. It is the most sensitive part of the retina, which is located at the back of the eye. The retina turns light into electrical signals and then sends these electrical signals through the optic nerve to the brain, where they are translated into the images we see. When the macula is damaged, the center of your field of view may appear blurry, distorted, or dark.
Who is at risk?
Age is a major risk factor for AMD. The disease is most likely to occur after age 60, but it can occur earlier. Other risk factors for AMD include:
• Smoking. Research shows that smoking doubles the risk of AMD.
• Race. AMD is more common among Caucasians than among African-Americans or Hispanics/Latinos.
• Family history and Genetics. People with a family history of AMD are at higher risk. At last count, researchers had identified nearly 20 genes that can affect the risk of developing AMD. Many more genetic risk factors are suspected. You may see offers for genetic testing for AMD. Because AMD is influenced by so many genes plus environmental factors such as smoking and nutrition, there are currently no genetic tests that can diagnose AMD, or predict with certainty who will develop it. The American Academy of Ophthalmology (link is external) currently recommends against routine genetic testing for AMD, and insurance generally does not cover such testing.
Does lifestyle make a difference?
Researchers have found links between AMD and some lifestyle choices, such as smoking. You might be able to reduce your risk of AMD or slow its progression by making these healthy choices:
• Avoid smoking
• Exercise regularly
• Maintain normal blood pressure and cholesterol levels
• Eat a healthy diet rich in green, leafy vegetables and fish
How is AMD detected?
The early and intermediate stages of AMD usually start without symptoms. Only a comprehensive dilated eye exam can detect AMD. The eye exam may include the following:
• Visual acuity test. This eye chart measures how well you see at distances.
• Dilated eye exam. Your eye care professional places drops in your eyes to widen or dilate the pupils. This provides a better view of the back of your eye. Using a special magnifying lens, he or she then looks at your retina and optic nerve for signs of AMD and other eye problems.
• Amsler grid. Your eye care professional also may ask you to look at an Amsler grid. Changes in your central vision may cause the lines in the grid to disappear or appear wavy, a sign of AMD.
• Fluorescein angiogram. In this test, which is performed by an ophthalmologist, a fluorescent dye is injected into your arm. Pictures are taken as the dye passes through the blood vessels in your eye. This makes it possible to see leaking blood vessels, which occur in a severe, rapidly progressive type of AMD (see below). In rare cases, complications to the injection can arise, from nausea to more severe allergic reactions.
• Optical coherence tomography. You have probably heard of ultrasound, which uses sound waves to capture images of living tissues. OCT is similar except that it uses light waves, and can achieve very high-resolution images of any tissues that can be penetrated by light—such as the eyes. After your eyes are dilated, you’ll be asked to place your head on a chin rest and hold still for several seconds while the images are obtained. The light beam is painless.
During the exam, your eye care professional will look for drusen, which are yellow deposits beneath the retina. Most people develop some very small drusen as a normal part of aging. The presence of medium-to-large drusen may indicate that you have AMD.
Another sign of AMD is the appearance of pigmentary changes under the retina. In addition to the pigmented cells in the iris (the colored part of the eye), there are pigmented cells beneath the retina. As these cells break down and release their pigment, your eye care professional may see dark clumps of released pigment and later, areas that are less pigmented. These changes will not affect your eye color.
Currently, no treatment exists for early AMD, which in many people shows no symptoms or loss of vision. Your eye care professional may recommend that you get a comprehensive dilated eye exam at least once a year. The exam will help determine if your condition is advancing.
As for prevention, AMD occurs less often in people who exercise, avoid smoking, and eat nutritious foods including green leafy vegetables and fish. If you already have AMD, adopting some of these habits may help you keep your vision longer.
Diabetic retinopathy People with diabetes can have an eye disease called diabetic retinopathy. This is when high blood sugar levels cause damage to blood vessels in the retina. These blood vessels can swell and leak. Or they can close, stopping blood from passing through. Sometimes abnormal new blood vessels grow on the retina. All of these changes can steal your vision. non-proliferative diabetic retinopathy) This is the early stage of diabetic eye disease. Many people with diabetes have it With NPDR, tiny blood vessels leak, making the retina swell. When the macula swells, it is called macular edema. This is the most common reason why people with diabetes lose their vision Also with NPDR, blood vessels in the retina can close off. This is called macular ischemia. When that happens, blood cannot reach the macula. Sometimes tiny particles called exudates can form in the retina. These can affect your vision too. If you have NPDR, your vision will be blurry. PDR (proliferative diabetic retinopathy) PDR is the more advanced stage of diabetic eye disease. It happens when the retina starts growing new blood vessels. This is called neovascularization. These fragile new vessels often bleed into the vitreous. If they only bleed a little, you might see a few dark floaters. If they bleed a lot, it might block all vision. These new blood vessels can form scar tissue. Scar tissue can cause problems with the macula or lead to a detached retina. PDR is very serious, and can steal both your central and peripheral (side) vision.
• Open angle glaucoma- usually bilaterally/optic disk cupping/genetic/ ESSENTIAL NO SYMPTOMS EARLY ON, BILATERAL LOSS OF PERIPHERAL VISION/CUPPING OPTIC DISC/INCREASED INTRAOCULAR PRESSURE, acute angle closure glaucoma is an immediate referral to optho. ) In open-angle glaucoma, the angle in your eye where the iris meets the cornea is as wide and open as it should be, but the eye’s drainage canals become clogged over time, causing an increase in internal eye pressure and subsequent damage to the optic nerve. It is the most common type of glaucoma/ In open angle glaucoma, the drainage canal of the eye called the trabecular meshwork is not anatomically blocked. We explain to our patients that open angle glaucoma is like a clogged drain. The drainage canal becomes clogged and allows less fluid to leave the eye. The eye continues to make fluid in the ciliary body and therefore, the pressure in the eye starts to rise. Over time, a high pressure in the eye causes optic nerve damage. Vision loss in open angle glaucoma starts with the far peripheral vision. The dangerous thing about open angle glaucoma is that it is painless and if you do not get regular eye exams, significant damage can occur without the patient noticing. Open angle glaucoma runs in families and is usually treated with eye drops to lower the pressure. Our board certified eye doctors also use a laser called Selective Laser Trabeculoplasty (SLT) to lower the intraocular pressure. With SLT, a cold laser is used to safely open the drainage canal of the eye and lower the intraocular pressure. For those patients that are not well controlled with eye drops or do not want to use eye drops, SLT is a great way to lower the pressure in the eye. However, at times it is necessary to do more conventional surgery to lower the eye pressure.
• Metal FB in eye, how do you evaluate and how do you remove? Do visual acuity first LEAVE A RUST RING, REQUIRES EXCISION OF THE AFFECTED TISSUE AND IS BEST DONE UNDER LOCAL ANESTHESIA USING A SLIT LAMP
• Penetrating eye injury treatment-complication facial fx and loss of vision, avoid pressure may cause rupture and loos of vitreous humor (results in blindness), don’t not preform fluorescein stain if suspected globe injury, for exam donut ring with 4inch gauze, apply antibiotic ointment, place cup on top of gauze
• Corneal abrasions: eval, presentation, medications (tetracaine onset 25 sec & 15 min duration, erythromycin or gentamicin/tobex , teaching, follow up/referral? – trauma to the anterior globe of the eye, only remove superficial foreign bodies, perform visual acuity, pupil response, visualize and inspect the orbital rim, verify equivocal sensation to orbit rim, corneal reflex (cotton wisp test), assess for subconjunctival hemorrhage, infection. EYE exam inspects anterior globe for clarity, hyphema, red reflex, lens opacity, vitreous and optic disc appearance, retinal abnormalities. Emergent referral for chemical acid or alkali exposure, flush with 0.9% NS for 15 minutes or 2 liters, to assess for abrasion use woods lamp, instill fluorescein drops, appears bright yellow or yellow green with woods lamp, irrigate vigorous with NS solution, if abrasion present apply topical antibiotics, apply eye patch
FB removal not superficial use 27-25 gauge needle bevel side up, after removing any FB check for corneal abrasion, instructions no driving, eye patch no longer than 48 hrs or amblyopia (lazy eye), tentus if not within 5 years, Tylenol with codeine 24hrs then palin Tylenol, avoid all topical ophthalmic anesthetic and nonsteroidal d/t retardation in healing can occur, no rubbing eye, return 24-48 hrs, return sooner for increased pain, drainage, loss of vision
Corneal infection: early signs is manifested by a white necrotic area around the crater and a small amount of gray exudate. Refer to opthomologist
• Orbital cellulitis: presentation, S&S -FEVER, PROPTOSIS, RESTRICTION OF EXTRAOCULAR MOVEMENTSAND SWELLING WITH REDNESS OF THE LIDS. IMMEDIATE TREATMENT WITH IV ANTIBIOTICS TO PREVENT OPTIC NERVE DAMAGE AND SPREAD OF INFECTION TO THE CAVERNOUS SINUSES/MENINGES AND BRAIN. CAUSE INFECTION OF THE PARANASAL SUNUSES/ ORGANISMS ARE S pneumoniae, treatment with penicillinase-resistant penicillin’s such as nafcillin or together with metronidazole or clindamycin to treat anaerobic infections. If trauma is the cause use cephalosporin such as cefazolin or ceftriaxone, MRSA use vanco or clindamycin. Surgery may be required . ALLERGY TO PCN USE VANCO, LEVOFLOXACIN, METRONIDAZOLE. IF IMMUCOMPROMIZED CONSIDER USING ZYGOMYCOSIS, REF TO OPTHO EMERGENTLY
• Orbital fractures: patho and causes, teaching for post-op/or discharge? Orbital fractures are commonly seen with midfacial trauma. Eye trauma, car accident or abuse. increased intraorbital pressure causes a decompressing fracture into an adjacent sinus. The Buckling theory contends that the posterior transmission of a direct orbital rim force causes a buckling and resultant fracture of the orbital wall. Both mechanisms may be involved to various degrees to produce orbital blow-out fractures. Orbital tissue (fat, fibrous septa, extraocular muscle) may be involved with the fracture site, resulting in ocular motility disturbance, while volume augmentation leads to globe malpositioning. Initial treatment in patients with facial injuries should be aimed at airway security, hemodynamic stability, and cervical-spine integrity. Head injuries must be ruled out. The patient should be evaluated for additional soft-tissue and bony injuries of the head and neck. The importance of recording visual acuity cannot be overemphasized/periocular ecchymosis and edema are present, position of the globe needs assessing. Patients should avoid blowing their nose and performing Valsalva maneuvers to limit intraorbital emphysema.
• Visual loss with acute orbital emphysema has been reported.
• Oral antibiotic therapy may be considered. Fractures that involve the medial wall and floor may be considered open fractures, as laceration of the sinus mucosa is inevitable.
• Analgesia and antiemetics may be required.
• The use of oral steroids (prednisone 1 mg/kg/d) has been advocated to decrease soft-tissue edema.
Different types of hearing loss and why they occur- Conductive/Sensorineural Conductive hearing loss is from external or middle ear dysfunction, a decrease in sound vibration to the inner ear 1. Obstruction (wax), 2. Mass loading (middle ear effusion) 3. Stiffness (otosclerosis- a hereditary disorder causing progressive deafness due to overgrowth of bone in the inner ear) 4. Discontinuity (ossicular disruption) . Most common ear wax and transient Eustachian tube disfunction from upper respiratory infection. Persistent conductive loss D/T chronic ear infections, trauma, or otosclerosis. Corrected with medical or surgical treatment
Sensorineural hearing loss- deterioration of cochlea, loss of hair cells, gradually progressive, high frequency loss with advanced age, other causes excessive loud noises head trauma and diseases, not correctable. Sudden loss can be treated with corticosteroids if given within several weeks of onset. Neural hearing loss involve the 8th cranial nerve (causes acoustic neuroma, MS and auditory neuropathy)
Weber Test – tuning fork on forehead, top of head, front teeth. In conductive loss the sound appears louder in the poorer hearing ear, with sensorineural radiates to better ear. Rinne Test tuning fork on mastoid bone and in front of the ear canal. In Conduction bone exceeds air conduction; In Sensorineural the opposite is true
Acute otitis media: causes, trx, presentation- Otalgia, erythema and hypomobility of tympanic membrane, pressure, decreased hearing, fever, mastoid tenderness (ruptured of tympanic membrane is accompanied by sudden decrease in pain and followed by otorrhea) usually follows or is with a upper respiratory infection, bacterial eustachian tube obstruction with fluids and mucous, most common bacteria Streptococcus pneunomiae, haemophilus influenzae, streptococcus pyogenes. TX- antibiotics and nasal decongestions , first line amoxicillin 80-90mg/kg/day divided twice a day, or erthyro 50mg/kg/day, sulfonamide 150mg/kg/day
Reoccurring infection treat with sulfamethoxazole 500mg or amoxicillin 250mgor 500mg 1 dose per day for 1-3 months.
Vertigo, how do you evaluate and trx? Spinning, Peripheral( onset is sudden, tinnitus and hearing loss, horizontal nystagmus may be present, unable to walk or stand, nausea / vomiting, causes labyrinths/Meniere disease (inner ear disorder)/ benign postural vertigo/ etoh/ inner ear .( evaluate the ears, eye moments, cranial nerve testing and Romberg test) Central – onset is gradual, no auditory symptoms, nystagum not always present, episodic events can occur due to diplopia, cerebral lesions involving the temporal cortex can cause vertigo, evaluate with audiogram/ electronystagmography or videonystagmography and head MRI (seizures, MS,) Side effect of medications
Labyrinthitis-acute onset of continues vertigo lasting days or week, unk cause, hearing loss and tinnitus, if febrile or symptoms of infection give antibiotics, meclizine
Epistaxis: causes, trx, what to look for in complications? Infection?
Causes-trauma, nose picking, FB, nose blowing, rhinitis, dry MM, nasal O2, deviated septum, atherosclerotic disease, cocaine, osler-weber-rendu syndrome, etoh.
Anterior bleeding direct pressure, sitting position, leaning forward, 1-2 sprays of decongestant (phenylephrine 0.125-1%) , if bleeding doesn’t stop use cocaine 4% or teracaine/lidocaine
POSTERIOR bleeds associated with atherosclerotic dx and hypertension
Reduce the risk of toxic shock syndrome when packing is in palce give CEPHALEXIN 500MG 4X DAY OR CLINDAMYCIN 150 MG 4X DAY
Complications: Nasal Packing
A. Septal Hematoma or abscess
1. Avoid excessive Trauma on Nasal Packing insertion
B. Septal pressure necrosis
1. Avoid overly tight Nasal Packing
C. Risk of Sinusitis or Toxic Shock Syndrome
1. Apply Bactroban Topical Ointment in nares
2. Oral antibiotic prophylaxis indications are patient specific
a. Optional in otherwise healthy patients
b. Recommended if SBE Prophylaxis would otherwise be indicated
c. Amoxicillin at standard treatment doses is reasonable option
d. Derkay (1989) Arch Otolaryngol Head Neck Surg 115: 439-441 [PubMed]
e. Bandhauer (2002) Am J Rhinol 16(3): 135-139 [PubMed]
IV. Preparation: Local Anesthetic and Topical Decongestant
A. Lidocaine 2% and Phenylephrine 4% mix 1:1 on cotton or
B. Afrin and Cetacaine sprayed into nare separately
A. Gown prior to Nasal Packing (bloody procedure)
B. Use topical Bactroban in nares with packing
C. Remove non-absorbable nasal packs after 2-3 days
1. Prolonged Nasal Packing has been associated with Toxic Shock Syndrome
2. Jacobson (1986) Arch Otolaryngol Head Neck Surg 112: 329-32 [PubMed]
D. The packing tip should be barely visible in the posterior pharynx when the patient opens their mouth
VI. Preparations: Nasal Packing options
A. Rocket pack (Rhino Rocket)
1. Easiest of all methods and most common in Emergency Departments
2. Two lengths (short for anterior bleed, long for posterior or unknown)
3. Soak for 30 seconds in sterile water, insert and inflate
B. Vaseline Gauze pack or 0.5 x 72 inch strips
1. Use Bayonet forceps with nasal speculum
2. Layer (accordion-fold) from bottom to top
3. Start each layer as far posterior as possible
4. Press down each layer before inserting next one
C. Absorbable Gelatin foam (Gelfoam)
D. Oxidized Cellulose (Surgicel)
E. Nasal tampon (Merocel or Doyle sponge)
1. Easier to insert then gauze pack method
2. Gently insert along floor of nose
3. Expand with saline or Phenylephrine
4. Absorbable oxidized cellulose
a. Effective for those on Anticoagulants
b. Do not need to be removed (will absorb)
VII. Patient Instructions
A. Return for removal of non-absorbable packs in 2-3 days
B. Apply Bactroban Topical Ointment in nares
C. Avoid vasodilating actions
1. Physical exertion
2. Spicy foods
D. Avoid Nasal manipulation or nose blowing
E. Sneeze with mouth open
F. Alleviate drying
1. Saline Nasal Sprays several times per day
2. Apply Bacitracin ointment qd to bid
3. Vaseline does not appear effective in children
Bacterial sinusitis: treatment, presentation, when you suspect it, what is GOLD standard of dx testing… purulent yellow/green nasal discharge or expectoration, facial pain or pressure, cough, malaise, fever and headache, nasal obstruction, or congestion, dental pain, halitosis, a result of impaired mucociliary clearance and obstruction of the ostiomeatal complex or sinus pore, bacteria- S. pneumoniae, streptococci, H influenza, VIRAL VS BACTERIAL- BACTERAIL LAST LONGER THAN 10 DAYS FROM ONSET, acute last less than 4 weeks, subacute 4-12 weeks, most common maxillary (largest and with only 1 pathway for drainage) unilateral face fullness/tenderness/pressure over check/ incisor pain. Ethmoid (between the eyes radiate to orbits, nose) Sphenoid (headache middle of head), Frontal (forehead, below eyebrow, orbit rim) Hospital acquired from NGT
TREATMENT-NSAIDS, ORAL PSEUDOEPHEDRINE 30-60MG Q 6 HRS MAX 240MG/DAY, NASAL METAZOLINE .05% 1-2 SPRAYS EACH NOSESTRIL Q6-8HRS UP TO 3 DAYS, INTRANASL CORTESTEROIDS, CONSIDER ANTIBIOTICS AFTER 10 DAYS OF SYMPTOMS, FIRST LINE ANTIBIOTICS IS AMOXICILLIN-CLAVULANATE 500MG/125 ORAL 3X DAY FOR 5-7 DAYS, OR 875MG/125 2X DAY 5-7 DAYS. IF ALLERGIC TO PCN THEN DOXY 100MG 2X DAY OR 200MG 2XDAY 5-7 DAYS.
HOW TO DX-USUALLY MADE BY CLINICAL SYSMPTOMS, CT NOCONTRAST IF TUMOR OR OTHER OPPORTUNISTIC INFECTION SUSPECTED THEN MRI WITH GAD.
Frontal Sinus Transillumination- put the ear scope light under the eyebrow cup your hand over the eye(light) and you should see a warm red glow
Maxillary Sinus Transillumination- ask patient to tilt their head back and open their mouth place light source against the cheek below the eye a red glow on the hard palate indicates a normal air filled sinus
Tonsillitis presentation- srtep concerns, (fever over 38c, anterior cervical adenopathy, lack of cough, pharyngotonsillar exudate) 2-3 symptoms still maybe strep.
White purple exudate= mono
DX- by swab culture or rapid antigen detection testing (RADT)
Treatment- benzathine PCN or procaine PCN 1.2 million units IM or Penicillin V 250 mg 3x day or 500mg 2x day for 10days
Complication scarlet fever
Familiarize yourself with diagnostic studies for evaluation eye conditions in acute situations * Slit lamps, Snellen chart, Wood’s lamp
Amsler grid- The Amsler grid, used since 1945, is a grid of horizontal and vertical lines used to monitor a person\\\'s central visual field. The grid was developed by Marc Amsler, a Swiss ophthalmologist. It is a diagnostic tool that aids in the detection of visual disturbances caused by changes in the retina, particularly the macula, as well as the optic nerve and the visual pathway to the brain.
• Beta adrenergic antagonists: side effects
• Cholinergic mimetics: side effects
• Prostaglandin analogs: side effects
• Osmotic diuretics: side effects
Bells palsy: S&S, treatment, pain management- sudden onset of lower motor neuron facial palsy, may worsen over the following day or so, pain to ear, face feels stiff and pulled to one side, hyperacusis (debilitating hearing )or impaired taste may occur, no other neurologic changes, inflammatory reaction involving the facial nerve near the stylomastoid foramen or in the bony facial nerve, usually resolves without tx , but prednisone 60mg q day for 5 dyas then 25mg 2x day for 10 days, treat with acyclovir only if herpetic vesicles in external ear, eye drops to eye, may use eye patch if eye does not close
Know epiglottis presentation, causes and treatment- rapid development of sore throat/odynophagia, bacterial or virus, H influenza, hospitalize for IV cefizoxime 1-2 g q 8-12 or cefuroxime 750-1000mg q 8hrs and dethamethasone 4-1- mg bolus than 4mg IV every 6 hrs
Know cranial nerves and their function-
• Chapter 10, “Heart Disease” (pp. 328-446)
• Chapter 11, “Systemic Hypertension” (pp. 447-478)
• Chapter 12, “Blood Vessel & Lymphatic Disorders” (pp. 479-506)
• Chapter 28, “Lipid Disorders” (pp. 1269-1277)
ACS protocol: low risk vs high risk mi- use of statins and ASA, ace inhibitors. High intensity statin therapy (atorvastatin 40-80mg, rosuvastion 20 -40 mg) mod intensity. MOST patients with vascular disease in the absence of heart failure or LV dysfunction should be treated with an ACE
Metabolic syndrome- (three or more of the following ) abdominal obesity, triglycerides 150mg/dl or high , HDL less than 40 for men, less than 50 for women, fasting glucose 110 or higher and hypertension.
Contraindications to thrombolytic therapy in stroke and MIs- ST elevation in AVR = left main or three vessel diseases. When the there is not an ST elevation, hemorrhagic stroke
MONA, what is it an when is it used? MONA is an acronym used to help medical professionals remember the initial treatment for acute coronary syndrome. MONA stands for morphine, oxygen, nitroglycerin and aspirin (“MONA greet chest pain patients at the door”).
Duke criteria for infective endocarditis, presentation and treatment-
Diagnostic : 2 Major Criteria and 0 Minor Criteria
Diagnostic : 1 Major Criteria and 3 Minor Criteria
Diagnostic : 0 Major Criteria and 5 Minor Criteria
Major Diagnostic Criteria
Positive blood culture for typical Infective Endocarditis organisms (strep viridins or bovis, HACEK, staph aureous without other primary site, enterococcus), from 2 separate blood cultures or 2 positive cultures from samples drawn > 12 hours apart, or 3 or a majority of 4 separate cultures of blood (first and last sample drawn 1 hour apart)
Echocardiogram with oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation, or abscess, or new partial dehiscence of prosthetic valve or new valvular regurgitation
Minor Diagnostic Criteria
Predisposing heart condition or intravenous drug use
Temp > 38.0° C (100.4° F)
Vascular phenomena: arterial emboli, pulmonary infarcts, mycotic aneurysms, intracranial bleed, conjunctival hemorrhages, Janeway lesions
Immunologic phenomena: glomerulonephritis, Osler nodes, Roth spots, rheumatoid factor
Microbiological evidence: positive blood culture but does not meet a major criterion as noted above or serological evidence of active infection with organism consistent with endocarditis (excluding coag neg staph, and other common contaminants)
Echocardiographic findings: consistent with endocarditis but do not meet a major criterion as noted above
Heart murmurs: physical exams, grades of murmurs-
Murmurs are sounds created by turbulent blood flow. They can occur at any time during the cardiac cycle. When you detect a murmur, you need to listen for a minute or more to determine its characteristics—the timing, pitch, quality, intensity, and pattern. You\\\'ll also want to identify where you hear it the loudest and if the sound radiates to other areas.
To establish timing, focus on whether you hear the murmur continuously, during systole (after S1 and before S2) or d