TEST – 2

DEEP VEIN THROMBOSIS

Text A
Deep vein thrombosis is a part of a condition called venous thromboembolism.

Deep vein thrombosis occurs when a blood clot (thrombus) forms in one or more
of the deep veins in the body, usually in the legs.

Deep vein thrombosis can cause leg pain or swelling, but may occur without any
symptoms.

Deep vein thrombosis is a serious condition because blood clots in the veins can
break loose, travel through the bloodstream, and obstruct the lungs, blocking blood
flow.

Text B
Clinical Manifestations
A major problem associated with recognizing DVT is that the signs and symptoms
are nonspecific.

Edema: With obstruction of the deep veins comes edema and swelling of the
extremity because the outflow of venous blood is inhibited

Phlegmasiaceruleadolens: Also called massive iliofemoral venous thrombosis, the

entire extremity becomes massively swollen, tense, painful, and cool to the touch.

Tenderness: Tenderness, which usually occurs later, is produced by inflammation

of the vein wall and can be detected by gently palpating the affected extremity.

Pulmonary embolus: In some cases, signs and symptoms of a pulmonary embolus

are the first indication of DVT

Medical Management

The objectives for treatment of DVT are to prevent thrombus from growing and
fragmenting, recurrent thromboemboli, and post thrombotic syndrome.
Endovascular management; Endovascular management is necessary for DVT when
anticoagulant or thrombolytic therapy is contraindicated, the danger of pulmonary
embolism is extreme, or venous drainage is so severely compromised that
permanent damage to the extremity is likely.

Vena cava filter: A vena cava filter may be placed at the time of thrombectomy;
this filter traps late emboli and prevents pulmonary emboli.

Discharge and Home Care Guidelines

The nurse must also promote discharge and home care to the patient.

Text C
Heparin (Rx)

Drug Strength Route of Recommended dosage FIRST PTT

Administration CHECK
1unit/mL Sc/IV 80 units/kg IV bolus, 6 hours after
2units/mL THEN continuous starting infusion
10units/mL infusion of 18
100units/mL units/kg/hr, OR
5000 units IV bolus,
THEN continuous
infusion of 1300
units/hr, OR
250 units/kg
(alternatively, 17,500
units) SC, THEN 250
units/kg q12hr

Drug education: The nurse should teach about the prescribed anticoagulant, its
purpose, and the need to take the correct amount at the specific times prescribed.
Blood tests: The patient should be aware that periodic blood tests are necessary to
determine if a change in medication or dosage is required.
Avoid alcohol: A person who refuses to discontinue the use of alcohol should not
receive anticoagulants because chronic alcohol intake decreases their effectiveness.
Activity: Explain the importance of elevating the legs and exercising adequately.
Text D
Nursing Care Planning & Goals

The major goals for the patient include:

Demonstrate increased perfusion as individually appropriate.

Verbalize understanding of condition, therapy, regimen, side effects of

medications, and when to contact the healthcare provider.

Engage in behaviors or lifestyle changes to increase level of ease.

Verbalize sense of comfort or contentment.

Maintain position of function and skin integrity as evidenced by absence of

contractures, foot drop, decubitus, and so forth.

Maintain or increase strength and function of affected and/or compensatory body

part.

Nursing Interventions

The major nursing interventions that the nurse should observe are:

Provide comfort; Elevation of the affected extremity, graduated compression

stockings, warm application, and ambulation are adjuncts to the therapy that can
remove or reduce discomfort.

Compression therapy: Graduated compression stockings reduce the caliber of the

superficial veins in the leg and increase flow in the deep veins; external
compression devices and wraps are short stretch elastic wraps that are applied from
the toes to the knees in a 50% spiral overlap; intermittent pneumatic compression
devices increase blood velocity beyond that produced by the stockings.

Positioning and exercise: When patient is on bed rest, the feet and lower legs
should be elevated periodically above the level of the heart, and active and passive
leg exercises should be performed to increase venous flow.
Part A

TIME: 15 minutes

 Look at the four texts , A – D, in the separate Text Booklet

 For each question, 1-20, look through the texts, A-d, to find the relevant
information.
 Write your answers on the spaces provided in this Question Paper.
 Answer all the questions within the 15-minute time limit.

DEEP VEIN THROMBOSIS

Questions 1-7
For each of the questions, 1-7, decide which text (A, B, C or D) the information
comes from. You may use any letter more than once

In which text can you find information about?

1. Endovascular management is for DVT …………………

2. Outflow of venous blood causing extreme swelling ………………….
3. The person receiving anticoagulants should avoid alcohol.
…………………
4. Deep vein thrombosis is asymptomatic sometimes …………………
5. Compression therapy reduces the caliber of the superficial veins in the leg
…………………
6. The importance of keeping legs elevated …………………
7. The nursing interventions …………………
Questions 8-14
Answer each questions, 8-4, with a word or short phrase from one of the texts.
Each answer may include words, number or the both. Your answers should be
correctly spelled.

8. What is the route of administration of heparin?

………………………………….
9. In which part of the body DVT normally occurs?
……………………………………..

10. When vena cava filler is used?

……………………………..
11. Which management is preferred for DVT if anticoagulant or thrombolytic
therapy is contraindicated?
………………………………
12. Which is the term used to describe the massive iliofemoral venous
thrombosis?
……………………………….
13. Which symptom usually occurs late in DVT?
………………………………
14. DVT is a part of a condition called?
…………………………………
Questions 15-20
Complete each of the sentences, 15- 20, with a word or short phrase from one of
the texts. Each answer may include words, number or both. Your answers should
be correctly spelled

15. A major problem is associated with recognizing DVT is that the signs and
symptoms are ………………………………….
16. Tenderness which usually occurs later is produced by……………….of the
vein wall
17. In some cases, signs and symptoms of a …………are the first indication.
18. First PPT check is ……………… hours after starting infusion.
19. 5000 units IV bolus, then continued infusion of ………units/hr.
20. The patient should be aware of periodic blood tests which are necessary to
determine if a change in ………………… or dosage is required.
 Part B
In this part of the test, there are six short extracts relating to the work of health
professionals. For questions 1-6, choose answer (A, B, or C) which you think fits
best according to the text.

1. The manual informs us that;

a. PMDD is used to prevent the incidence of assisted suicide and euthanasia
b. PMDD is a protective durable power of attorney for International Task
Force on euthanasia and assisted suicide
c. In PMDD the signer names a trusted person to make health care decisions

1. PROTECTIVE MEDICAL DECISIONS DOCUMENT (PMDD)

The PMDD is a protective Durable Power of Attorney for Health Care which is
available from the International Task Force on Euthanasia and Assisted Suicide. In
the PMDD the signer names a trusted person to make health care decisions in the
event that the signer is temporarily or permanently unable to make such decisions.
The PMDD, which specifically prohibits assisted suicide and euthanasia, is
available in a Multi-State version for use in most states. It is also available in state-
specific versions for states where particular requirements make a state-specific
version necessary.
 2. The paragraph is giving information about;
a. Types of bronchodilators
b. Uses of bronchodilators
c. Definition of bronchodilator

2.Bronchodilator

A bronchodilator is a substance that dilates the bronchi and bronchioles, decreasing

resistance in the respiratory airway and increasing airflow to the lungs.
Bronchodilators may be endogenous (originating naturally within the body), or
they may be medications administered for the treatment of breathing difficulties.
They are most useful in obstructive lung diseases, of which asthma and chronic
obstructive pulmonary disease are the most common conditions. Although this
remains somewhat controversial, they might be useful in bronchiolitis and
bronchiectasis. They are often prescribed but of unproven significance in
restrictive lung diseases.
 3.Use of ICD’S is;
a. Delivers an electric shock .
b. Prevents cardiac arrest in high risk patients.
c. It is a battery powered device

3. Implantable Cardioverter Defibrillator (ICD)?

An ICD is a battery-powered device placed under the skin that keeps track of your
heart rate. Thin wires connect the ICD to your heart. If an abnormal heart rhythm is
detected the device will deliver an electric shock to restore a normal heartbeat if
your heart is beating chaotically and much too fast. ICDs have been very useful in
preventing sudden death in patients with known, sustained ventricular tachycardia
or fibrillation. Studies have shown that they may have a role in preventing cardiac
arrest in high-risk patients who haven't had, but are at risk for, life-threatening
ventricular arrhythmias.
 4. Overhead radiant warmers

a. Minimize the oxygen and calories of infant

b. Is used to all neonates and infants
c. Provide neutral thermal environment for the patient

4. Monitoring Temperature Using an Overhead Radiant Warmer

Neonates, infants who are exposed to stressors or chilling (e.g., from undergoing
numerous procedures), and infants who have an underlying condition that
interferes with thermoregulation (e.g., prematurity) are highly susceptible to heat
loss. Therefore, radiant warmers are used for infants who have trouble maintaining
body temperature. In addition, use of a radiant warmer minimizes the oxygen and
calories that the infant would expend to maintain body temperature, thereby
minimizing the effects of body temperature changes on metabolic activity. An
overhead radiant warmer warms the air to provide a neutral thermal environment,
one that is neither too warm nor too cool for the patient. The incubator temperature
is adjusted to maintain and anterior abdominal skin temperature of 36.5C (97.7F),
but at least 36C (96.8F), using servocontrol (automatic thermostat)
 5.What should be done if the patient is not able to maintain flat position till
the end of Doppler ultrasound?

a. Elevate the legs of patient

b. Provide flat position according to patients comfort and document the
position given
c. Educate the patient regarding the importance of maintaining flat position
throughout the procedure

5. To ALL staff

Subj: PROCEDURE FOR VASCULAR ASSESSMENT BY DOPPLER

ULTRASOUND

The procedure should be explained to the patient and informed and understood
consent gained. Although it is not invasive it can be uncomfortable and for some
painful because the blood pressure cuff may squeeze the leg over existing
ulceration and/or oedema. Patients need to know what to expect so they can stop
the nurse from continuing should the pain become unbearable. This information
and patient’s comments on the procedure must be recorded in the patient health
record. Before carrying out the procedure the patient should rest for 10 to 20
minutes (Carter 1969 et al). The emphasis is upon obtaining the resting systolic
pressure. Time should be allowed within the nursing schedule for the patient to be
rested. The patient should also lie flat in order to minimize hydrostatic pressure
variables (Vowden and Vowden 2001). However, many patients will not be able to
lie flat and for some having their legs elevated is difficult e.g. in the case of
patients with breathing problems or arthritis. In these cases lie the patients as flat as
comfortably tolerated and/or with legs elevated as much as possible. The patient’s
position should be documented. This will contribute to consistency for future
readings and put the ABPI within a context which relates to patient positioning.
 6.Antibiotics

a. Are used to treat viral infections.

b. Act by killing bacteria.
c. Are used to treat common cold or influenza.

6. Antibiotic

An antibiotic (from ancient Greek αντιβιοτικά, antibiotiká), also called an

antibacterial, is a type of antimicrobial drug used in the treatment and prevention
of bacterial infections. They may either kill or inhibit the growth of bacteria. A
limited number of antibiotics also possess antiprotozoal activity. Antibiotics are
not effective against viruses such as the common cold or influenza; drugs which
inhibit viruses are termed antiviral drugs or antivirals rather than antibiotics.
 Part C
In this part of the test, there are two tests about different aspects of health care. For
questions 7 – 22, choose the answer (A, B, C , or D) which you think fits best
according to the text

Text 1: Viral Infection – Yellow Fever

Yellow fever is a viral infection spread by a particular species of mosquito. It's

most common in areas of Africa and South America, affecting travellers to and
residents of those areas. In mild cases, it causes fever, headache, nausea and
vomiting. But it can become more serious, causing heart, liver and kidney
problems along with bleeding (haemorrhaging). Up to 50 percent of people with
the more severe form of yellow fever die of the disease.

There's no specific treatment for yellow fever. But getting a yellow fever vaccine
before travelling to an area in which the virus is known to exist can protect you
from the disease. During the first three to six days after you've contracted yellow
fever — the incubation period — you won't experience any signs or symptoms.
After this, the virus enters an acute phase and then, in some cases, a toxic phase
that can be lifethreatening.

Once the yellow fever virus enters the acute phase, you may experience signs and
symptoms including: Fever, Headache, Muscle aches, particularly in your back and
knees, Nausea, vomiting or both, Loss of appetite, Dizziness, Red eyes, face or
tongue These signs and symptoms usually improve and are gone within several
days.

Although signs and symptoms may disappear for a day or two following the acute
phase, some people with acute yellow fever then enter a toxic phase. During the
toxic phase, acute signs and symptoms return and more-severe and life-threatening
ones also appear. These can include: Yellowing of your skin and the whites of your
eyes (jaundice), Abdominal pain and vomiting, sometimes of blood, Decreased
urination, Bleeding from your nose, mouth and eyes, Heart dysfunction
(arrhythmia), Liver and kidney failure, Brain dysfunction, including delirium,
seizures and coma. The toxic phase of yellow fever can be fatal.
Make an appointment to see your doctor four to six weeks before travelling to an
area in which yellow fever is known to occur. If you don't have that much time to
prepare, call your doctor anyway. Your doctor will help you determine whether
you need vaccinations and can provide general guidance on protecting your health
while abroad.

Seek emergency medical care if you've recently travelled to a region where yellow
fever is known to occur and you develop severe signs or symptoms of the disease.
If you develop mild symptoms, call your doctor.

Yellow fever is caused by a virus that is spread by the Aedes aegypti mosquito.
These mosquitoes thrive in and near human habitations where they breed in even
the cleanest water. Most cases of yellow fever occur in sub-Saharan Africa and
tropical South America.

Humans and monkeys are most commonly infected with the yellow fever virus.
Mosquitoes transmit the virus back and forth between monkeys, humans or both.
When a mosquito bites a human or monkey infected with yellow fever, the virus
enters the mosquito's bloodstream and circulates before settling in the salivary
glands. When the infected mosquito bites another monkey or human, the virus then
enters the host's bloodstream, where it may cause illness.

You may be at risk of the disease if you travel to an area where mosquitoes
continue to carry the yellow fever virus. These areas include sub-Saharan Africa
and tropical South America. Even if there aren't current reports of infected humans
in these areas, it doesn't mean you're risk-free. It's possible that local populations
have been vaccinated and are protected from the disease, or that cases of yellow
fever just haven't been detected and officially reported. If you're planning on
travelling to these areas, you can protect yourself by getting a yellow fever vaccine
at least 10 to 14 days before travelling. Anyone can be infected with the yellow
fever virus, but older adults are at greater risk of getting seriously ill.

Diagnosing yellow fever based on signs and symptoms can be difficult because
early in its course, the infection can be easily confused with malaria, typhoid,
dengue fever and other viral hemorrhagic fevers.

To diagnose your condition, your doctor will likely:

Ask questions about your medical and travel history Collect a blood sample for
testing

If you have yellow fever, your blood may reveal the virus itself. If not, blood tests
known as enzyme-linked immuno sorbent assay (ELISA) and polymerase chain
reaction (PCR) also can detect antigens and antibodies specific to the virus. Results
of these tests may not be available for several days.

No antiviral medications have proved helpful in treating yellow fever. As a result,

treatment consists primarily of supportive care in a hospital. This includes
providing fluids and oxygen, maintaining adequate blood pressure, replacing blood
loss, providing dialysis for kidney failure, and treating any other infections that
develop. Some people receive transfusions of plasma to replace blood proteins that
improve clotting. If you have yellow fever, you may also be kept away from
mosquitoes, to avoid transmitting the disease to others.
Text 1: Questions 7-14

7. Yellow fever is common in

A. Africa
B. South America
C. both
D. not given

8. Signs of yellow fever doesn’t include one of this

A. back pain
B. vomiting
C. nausea
D. dry tongue

9. Signs in toxic phase

A. loss of appetite
B. yellowness of eyes
C. brain dysfunction
D. B and C

10. Seizures may occur during

A. acute phase
B. toxic phase
C. sometimes in both the phases
D. not given

11. Yellow fever which is a viral disease, is spread by

A. Aedes agypti mosquito
B. Aedes aegypti mosquito
C. female mosquito
D. contamination
12. Mosquito transmits virus from
A. human to monkeys
B. monkeys to human
C. human to human
D none

13. Taking vaccine …………… days before travelling to areas where the disease is
common is recommended
A. 10 days
B. 12 days
C .14 days
D. 10-14 days

14. “It does not mean you are risk free” in paragraph 8 refers to?
A. there is a greater chance of infection in some areas even though there is no
recent report of infection
B. even thought there are no current reported cases of yellow fever in some areas,
there is still a risk of getting injection
C. it is always recommended to take vaccines before travelling to Africa and South
America
D. local population is not affected by yellow fever because of vaccination
Text 2: Aortic Dissection or Dissecting Aneurysm
An aortic dissection is a serious condition in which a tear develops in the inner
layer of the aorta, the large blood vessel branching off the heart. Blood surges
through this tear into the middle layer of the aorta, causing the inner and middle
layers to separate (dissect). If the blood-filled channel ruptures through the outside
aortic wall, aortic dissection is often fatal.

Aortic dissection, also called dissecting aneurysm, is relatively uncommon.

Anyone can develop the condition, but it most frequently occurs in men between
60 and 70 years of age. Symptoms of aortic dissection may mimic those of other
diseases, often leading to delays in diagnosis. However, when an aortic dissection
is detected early and treated promptly, your chance of survival greatly improves.

Aortic dissection symptoms may be similar to those of other heart problems, such
as a heart attack. Typical signs and symptoms include: Sudden severe chest or
upper back pain (often described as a tearing, ripping or shearing sensation, that
radiates to the neck or down the back), Loss of consciousness (fainting), Shortness
of breath, Sweating, Weak pulse in one arm compared to the other etc.

If you have signs or symptoms such as severe chest pain, fainting, sudden onset of
shortness of breath or symptoms of a stroke then taking medical assistance is of
preliminary importance. While experiencing such symptoms doesn't always mean
that you have a serious problem, it's best to get checked out quickly. Early
detection and treatment may help save your life.

An aortic dissection occurs in a weakened area of the aortic wall. Chronic high
blood pressure may stress the aortic tissue, making it more susceptible to tearing.
You can also be born with a condition associated with a weakened and enlarged
aorta, such as Marfan syndrome or bicuspid aortic valve. Rarely, aortic dissections
may be caused by traumatic injury to the chest area, such as during motor vehicle
accidents.

Aortic dissections are divided into two groups, depending on which part of the
aorta is affected:
Type A: This is the more common and dangerous type of aortic dissection. It
involves a tear in the part of the aorta just where it exits the heart or a tear
extending from the upper to lower parts of the aorta, which may extend into the
abdomen.
Type B: This type involves a tear in the lower aorta only “ which” may also
extend into the abdomen.

Risk factors for aortic dissection include: Uncontrolled high blood pressure
(hypertension), found in at least two-thirds of all cases Hardening of the arteries
(atherosclerosis) Weakened and bulging artery (pre-existing aortic aneurysm) An
aortic valve defect (bicuspid aortic valve) A narrowing of the aorta you're born
with (aortic coarctation)

People with certain genetic diseases are more likely to have an aortic dissection
than are people in the general population.
These include: Turner's syndrome. High blood pressure, heart problems and a
number of other health conditions may result from this disorder.
Marfan syndrome; This is a condition in which connective tissue, which supports
various structures in the body, is weak. People with this disorder often have a
family history of aneurysms of the aorta and other blood vessels. These weak
blood vessels are prone to tears (dissection) and rupture easily.
Ehlers-Danlos syndrome; This group of connective tissue disorders is characterized
by skin that bruises or tears easily, loose joints and fragile blood vessels.
Loeys-Dietz syndrome; This is a connective tissue disorder marked by twisted
arteries, especially in the neck. People who have Loeys-Dietz syndrome are
thought to be at risk for developing aortic dissections and aneurysms.
An aortic dissection can lead to death, due to severe internal bleeding, including
into the lining around the heart (pericardial sac), Organ damage, such as kidney
failure or life-threatening damage to the intestines, Stroke, possibly including
paralysis, Aortic valve damage, such as causing the aortic valve to leak (aortic
regurgitation)
Detecting an aortic dissection can be tricky because the symptoms are similar to
those of a variety of health problems. Doctors often suspect an aortic dissection if
the following signs and symptoms are present: Sudden tearing or ripping chest
pain, Widening of the aorta on chest X-ray, Blood pressure difference between
right and left arms.
Text 2: Questions 15 to 22

15. In aortic dissection a tear develops in

A. outer layer of aorta
B. inner layer of aorta
C. middle aorta
D. a blood vessel branching off the heart

16. Dissecting aneurysm is common among

A. men
B. women
C. both
D. children

17. Symptoms of aortic dissection include

A. chest pain and swelling
B. weak pulse in both arms
C. loss of consciousness
D. all of the above

18. Aortic dissection can also be caused due to

A. high BP
B. weak aortic wall
C. inborn symptoms
D. traumatic injury to chest during accidents

19. The most dangerous type of aortic dissection is

A. Type A
B. Type B
C. aortic aneurism
D. aortic coarctation

20. A condition in which connective tissue is weak

A. Turner’s syndrome
B. Loeys-Dietz syndrome
C. Ehlers-Danlos syndrome
D. Marfan’s syndrome
21. People with Loeys-Dietz syndrome are likely to develop
A. aneurysms
B. ruptured blood vessels
C. twisted arteries in the neck
D. aortic complications

22.In paragraph 6 ‘which’ refers to?

A. type B aortic dissection
B. the lower aorta
C. abdomen
D. a tear
ANSWER KEY
DEEP VEIN THROMBOSIS
1 B
2 B
3 C
4 A
5 D
6 C
7 D
8 SC/IV
9 Legs
10 Thrombectomy
11 Endovascular management
12 Phlegmasiaceruleadolens
13 Tenderness
14 Venous thromboembolism
15 Nonspecific
16 Inflammation
17 Pulmonary embolus
18 6
19 1300
20 medication
READING SUB- TEST- ANSWER KEY

PART B: QUESTIONS 1-6[PMDD]

1. A
2. B
3. B
4. C
5. B
6. B

C PART C: QUESTIONS 7-14[YELLOW FEVER]

7. C
8. D
9. D
10. B
11. B
12. A/B
13. D
14. B

PART C: QUESTIONS 15-22[AORTIC DISSECTION]

15. B
16. A
17. C
18. D
19. A
20. D
21. A
22. D