READING SUB-TEST: PART A

PART A -TEXT BOOKLET - 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 Phlegmasia Cerulea Dolens: 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 for the patient.
TEXT C

Heparin (Rx)

Recommended FIRST PTT

dosage
Drug Strength Route of Administration CHECK
80 units/kg IV bolus, THEN
continuous infusion of 18
units/kg/hr,

OR
1unit/ml 5000 units IV bolus, THEN
2units/ml Sc/IV continuous infusion of 6 hours after
1300 units/hr, starting infusion
10 units/Ml
OR
100 units/ml
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 deter mine 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 f low 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.

QUESTIONS 1 -7

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 8-1

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

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. ln 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.

READING SUB-TEST: PART B

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.

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 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

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 is;

a. Delivers an electric shock .
b. Prevents cardiac arrest in high-risk patients.
c. It is a battery powered device
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 warmer s

a. Minimize the oxygen and calories of infant
b. Is used to all neonates and infants
c. Provide neutral thermal environment for the patient

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 warm 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.SC (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

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. Anti biotics
a. Are used to treat viral infections.
b. Act by killing bacteria.
c. Are used to treat common cold or influenza.

Antibiotic

An antibiotic (from ancient Greek avtibalotika antibiotika), 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.

READING SUB-TEST : PART C

TEXT 1: VIRAL INFECTION – YELLO 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 SO 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
life threatening.

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 m1onkeys, 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 hU1man, 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 immune 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 7-1

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 Both A and B

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 dissect ion, 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 dissect ion 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 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 (pericardia! 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. ln paragraph 6 which' refers to?

A. type B aortic dissection
B. the lower aorta
C. abdomen
D. a tear