NUR 141 Midterms PDF

TABLE OF CONTENTS Altered Tissue Perfusion - p.2 Altered Elimination - p.10...

TABLE OF CONTENTS Altered Tissue Perfusion - p.2 Altered Elimination - p.10 Altered Perception - p.19 BATCH 2025 TRANXCN TEAM DEPUTY HEADS Dangue, Dana Louise C. Tan, Juliana Rose C. TRANXCN TEAM Acuesta, Jenine M. NUR 141 Barreyro, Karlo Gabriel A. Carbonel, Carl Vincent A. Castillo, Angelo D. Cosio, Mark Angelo B. ACUTE AND De Jesus, Ghalla Celine V. De Ramos, Arianne D. Gaurano, Samantha Gabrielle C. Gemaguim, Flerisse Jan I. Grafilo, Kyla Isabel H. BIOLOGIC CRISIS Himan, Conn Sigfrid M. Javier, Natalie Faith M. Legaspi, Marcus V. Legaspi, Zerline A. Maala, Kyleen Beatrice A. Matutina, Laurie Jed A. Naval, Jann Danielle A. TranxCN: MIDTERM RELEASE A.Y. 2024-2025 Quiza, Kirsten Nichole M. Ribon, Princess Ghel V. Umali, Charles Joseph B. Guidelines: The Tranx CN is NOT FOR SALE and shall only be utilized by the bona fide nursing students from De La Salle medical and Health Sciences Institute. The students are permitted to download and print the Tranx CN. 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The College of Nursing Faculty/Professors are not liable for any mistakes or false information that may inadvertently be included in this transcript.  NUR 141: ACUTE AND BIOLOGIC CRISIS MIDTERMS RELEASE-NUR141-BSN48 ○ Paroxysmal nocturnal dyspnea (need of fresh air after a few hours of sleeping) ○ Increased thoracic pressure d/t increase OUTLINE accumulation of blood in the thoracic cavity A. Physiologic Cardiac Events for those with CHF B. Cardiovascular (Focus) Assessment C. Laboratory / Diagnostic Procedure SKIN Hydration, turgor and color PHYSIOLOGIC CARDIAC EVENTS Cyanosis Cardiac Output - Vol. of blood pumped by Central: inadeq. O2 sat. in arterial blood ventricles in liters/minute (4-6L/min) Peripheral: reduced blood flow ○ Decrease CO indicates heart problem Xanthelasma palpebrarum (ass. with Stroke Volume - Amount of blood ejected w/ each atherosclerosis, dyslipidemia and CAD) beat (70 ml/beat) Presence of abnormal skin pathologies e.g., bruises, Preload (LVED Pressure) - Initial myocyte etc. stretching prior to contraction - Stretching of the heart BLOOD PRESSURE Afterload (SVR) - Pressure that the heart needs to BP and Pulse measurement exert to eject blood during ventricular contraction - Postural BP changes high fowlers or semi fowlers Happens on last stage of cardiac circulation, (every change in position BP should be monitored) Increase contraction to push blood Electrophysiology ARTERIAL PULSES ○ SA 60-100 impulse per min – AV 60-40 Rate impulse per min - Bundle of His (none) pass Rhythm thru only – Purkinje Fibers 40-20 impulse Quality per min Configuration Cardiac Circulation Effect of Vessel Quality of Pulse SVC/IVC → RA → TV → RV → PV → PA → PV → ○ Jugular Vein Pulsation LA → MV → LV → AV → Aorta ○ Pulsus alterans: HF and cardiac tamponade Frank-Starling Law - Cardiac input (SV) deoxygenated blood and cardiac output oxygenated Becks triad: Muffled heart sounds, blood are matched hypotension, distended neck veins Poiseuille Law - Flow of liquid (blood) will depend Identify jugular venous pulsation and their highest on length of the vessel (tube), radius, pressure point in the neck. Start with the head of the bed 30 gradient, and viscosity of fluid degrees; adjust angle of the bed as necessary. Study the waves of venous pulsation. Note a wave CARDIOVASCULAR (FOCUS) ASSESSMENT of atrial contraction and the v wave of venous filling. HEALTH HISTORY ○ Absent a waves in atrial fibrillation; Clinical Manifestations - baseline data prominent v waves in tricuspid regurgitation Activity and Exercise Measure jugular venous pressure (JVP) - the vertical Sleep and Rest distance between the highest point and the sternal Cognition and Perception angle, normally 24hrs Orthopnea “decreased ability to breathe when lying down LACTIC DEHYDROGENASE “d/t delayed medical intervention” ABDOMEN Onset: 12hrs Hepatojugular Reflux Peaks: 48hrs ○ Liver engorgement d/t dec. venous return 2° RTN: 10-14 days RVF. ○ Press RUQ 30-60s and a 1cm or more rise BLOOD CHEMISTRY in JVP. (+) inability of the right side to Lipid profile/panel or cholesterol levels: “risk for maintain cardiac input. developing atherosclerotic disease” – Cholesterol, Bladder Distension LDLs, HDLs, triglyceride ○ U/O reduced indicates dec. renal perfusion Serum electrolytes: Na, K, Ca, Mg or retention. BUN: “end product of protein metabolism and excreted by the kidneys” LOWER EXTREMITIES Serum glucose: “mildly elevated in stressful events” Clubbing Ulcerations COAGULATION STUDIES Varicosities PTT and aPPT Sensation Values of the two are used to assess the effects of Capillary perfusion heparin therapy. Symmetry in limb circumference ACUESTA, DE RAMOS, JAVIER, MAALA, NAVAL, QUIZA, RAMIREZ, RIBON, UMALI 3 of 26 The CNSC does not intend to substitute learning materials provided by the College and its faculty. Use at your own discretion.  NUR 141: ACUTE AND BIOLOGIC CRISIS MIDTERMS RELEASE-NUR141-BSN48 PTT: 60 to 70 seconds Pressures and O2 sats are measured in the four aPTT: 30 to 45 seconds chambers. Will determine if revascularization procedures are PT warranted. Monitor the effects of therapeutic anticoagulation with warfarin. 11 to 16 seconds CENTRAL VENOUS PRESSURE MONITORING HEMATOLOGY STUDIES Pressure in the VC and RA measured to assess RV RBC function and venous return. WBC Assess fluid volume status Hemoglobin Normal range: 0 to 8mmHg or 3 to 8cm H2O. Hematocrit ○ Increased: hypervolemia or HF ○ Decreased: reduced RV preload d/t NON-INVASIVE Hypovolemia Electrocardiography If LVF precedes RVF, CVP is not useful: elevated ○ Electrical impulses CVF is a late sign of LVHF Echocardiography ○ Sound waves INTRA-ARTERIAL BP MONITORING Obtains direct and continuous BP measurement w/ severe hypertension/hypotension. Arterial catheters are useful for ABG and blood sample taking. Complications: local obstruction w/distal ischemia, INVASIVE CARDIAC CATHETERIZATION Radiopaque inserted in the left and right side of the heart w/ fluoroscopy. ACUESTA, DE RAMOS, JAVIER, MAALA, NAVAL, QUIZA, RAMIREZ, RIBON, UMALI 4 of 26 The CNSC does not intend to substitute learning materials provided by the College and its faculty. Use at your own discretion.  NUR 141: ACUTE AND BIOLOGIC CRISIS MIDTERMS RELEASE-NUR141-BSN48 PACEMAKER (IMPLANTABLE) Detects changes in the heart’s rhythm and pacing. If defib is required, place pads one inch away from the device. It sends a signal to the heart that makes the heartbeat at the correct pace. NURSING DIAGNOSIS Activity Intolerance related to insufficient oxygen for Activities of Daily Living Anxiety related to Breathlessness Imbalanced Nutrition: Less than Body Requirements related to Nausea; Anorexia Secondary to Venous Congestion Impaired Peripheral Tissue Perfusion related to Venous Congestion Disturbed Sleeping Pattern related to Nocturnal Dyspnea Powerlessness related to Progressive Nature of Condition High Risk for Ineffective Therapeutic Regimen Management related to Lack of Knowledge Pain related to Impaired Circulation PLANNING Recognize Myocardial Ischemia Relieve Chest Pain CARDIOVERTERS Maintain a calm environment Cardioverts and defibrillates the heart preventing Balance of Myocardial Oxygen Supply and Demand sudden death. Optimize Cardiopulmonary Function Two types: Promote Comfort and Emotional Support ○ Traditional ICD (highly invasives Monitor Effects of Pharmacological Therapy ○ S-ICD (minimally invasive Patient Education MEDICAL / SURGICAL MANAGEMENT RECANALIZATION Percutaneous Transluminal Angioplasty CABG Involves blind threading of a glide wire through the trabeculated vein. Revascularization is the main goal of recanalization. Revascularization procedures can be PCIs or CABG. ACUESTA, DE RAMOS, JAVIER, MAALA, NAVAL, QUIZA, RAMIREZ, RIBON, UMALI 5 of 26 The CNSC does not intend to substitute learning materials provided by the College and its faculty. Use at your own discretion.  NUR 141: ACUTE AND BIOLOGIC CRISIS MIDTERMS RELEASE-NUR141-BSN48 Removal of the diseased heart and replacement of ABLATION the donor heart. Scars tissue to block irregular electrical signals. Will be in CPB, monitor coag. studies d/t the Treats arrhythmias. unfractionated heparin use. PHARMACOLOGICAL MANAGEMENT Indications for catheter and surgical ablation FIRST & SECOND-LINE PHARMACOTHERAPY Catheter Ablation Surgical Ablation CLASS ACTION Paroxysmal atrial Non-paroxysmal AF fibrillation (AF) Failed catheter Anticoagulants blood thinners, reduce First-time ablation ablation coagulation, prolonging clotting Redo procedures Indication for left atrial Patient choice appendage occlusion Patient Thrombolytics clot buster; used in ST elevation (Fibrinolytics) MI, stroke, severe venous thromboembolism Inotropes negative - decrease muscle strength (i.e. amiodarone) positive - increase muscle strength (i.e. epinephrine, dobutamine) Anti-HTNs lower BP IABP Antiarrhythmic prevents abnormal rhythm (i.e. A balloon catheter is placed in the descending propranolol) aorta, just below the left subclavian artery. The balloon is connected to a control system that Antiplatelet prevents platelet aggregation (i.e. inflates and deflates the balloon in sync with the aspirin, clopidogrel) heart's pumping cycle. Reduces the resistance to LV ejection (afterload) COMPLEMENTARY/ALTERNATIVE THERAPIES and increases coronary (diastolic pressure) and Fish oil/Omega 3 - alternative that lowers LDLs & systemic blood flow triglycerides Fatty Acids - fat storage (i.e. linoleic acid) Hawthorn - BP & Cholesterol Gingko Biloba: “known to have blood thinning component”; GOOD FOR MEMORY! Ginseng: “increases heart rate” Garlic: “Cholesterol control; lowering BP” ALTERED PERFUSION FUNCTION - DISEASES CORONARY ARTERY DISEASE Most prevalent CVD Most common heart disease is atherosclerosis; arteriosclerosis RISK FACTOR DETAILS NON-MODIFIABLE Family hx of coronary heart disease Increasing age HEART TRANSPLANT ACUESTA, DE RAMOS, JAVIER, MAALA, NAVAL, QUIZA, RAMIREZ, RIBON, UMALI 6 of 26 The CNSC does not intend to substitute learning materials provided by the College and its faculty. Use at your own discretion.  NUR 141: ACUTE AND BIOLOGIC CRISIS MIDTERMS RELEASE-NUR141-BSN48 ○ Reduction of myocardial oxygen demand or Gender (3x more increasing the oxygen supply common in men than ○ Pain management premenopausal women) Race (higher HEART FAILURE incidence in Clinical syndrome involving inadequate pumping African-Americans and/or filling of the heart. than in Caucasians) Early signs: Fatigue, Hepatomegaly, Exertional, paroxysmal, nocturnal dyspnea, Neck vein MODIFIABLE High blood engorgement cholesterol level Complications: Pulmonary edema, hypoperfusion Cigarette smoking, Primary Causes: CAD (including myocardial tobacco use infarction), HTN, rheumatic heart disease, Hypertension congenital heart defects, pulmonary HTN, Diabetes mellitus cardiomyopathy, hyperthyroidism, valvular Lack of estrogen in disorders, myocarditis women Physical inactivity TYPES OF HEART FAILURE Obesity TYPE DEFINITION CAD: PATHOPHYSIOLOGY Summary Left-sided Left ventricles are unable to pump 1. Chronic endothelial injury - due to risk factors the blood properly mentioned above 2. Fatty streak - lipids accumulate and migrate Right-sided Right ventricles are unable to pump into smooth muscle cells the blood properly 3. Fibrous plaque - collagen covers fatty streak, Diastolic Muscles of the heart become stiffer vessel lumen is narrowed, blood flow reduced, or harder than normal fissures may develop 4. Complicated lesion - plaque rupture, thrombus Systolic Muscles of the heart are unable to formation, further narrowing or total occlusion of contract to pump out oxygenated vessel blood HF: PATHOPHYSIOLOGY RSHF LSHF SIGNS SIGNS RV heaves LV heaves Murmurs Pulsus alterans Jugular vein Increased HR distention PMI displaced Edema inferiorly and Wt gain posteriorly Increased HR Decreased PaO2, CAD: MANAGEMENT Ascites slight increase in Controlling risk factors (nutrition, smoking, exercise, Anasarca PaO2 stress, and medication adherence (massive Crackles Interventions such as drug therapy (nitrates – generalized (pulmonary nitroglycerin, ISDN, or beta-adrenergic blockers) edema) edema) Invasives: CABG, PTCA, Laser angioplasty S3 & S4 heart Other treatments: sounds ACUESTA, DE RAMOS, JAVIER, MAALA, NAVAL, QUIZA, RAMIREZ, RIBON, UMALI 7 of 26 The CNSC does not intend to substitute learning materials provided by the College and its faculty. Use at your own discretion.  NUR 141: ACUTE AND BIOLOGIC CRISIS MIDTERMS RELEASE-NUR141-BSN48 Hepatomegaly Pleural effusion (liver Changes in mental enlargement) status Restlessness, confusion SYMPTOMS SYMPTOMS Fatigue Weakness, fatigue Anxiety, Anxiety, depression depression Dependent, Dyspnea bilateral edema Shallow RUQ pain respirations up to Anorexia and GI 32-40/min bloating Paroxysmal Nausea nocturnal dyspnea Orthopnea CARDIOMYOPATHY Dry, hacking cough Nocturia Frothy, pink-tinged sputum COMPARISON OF TYPES OF CARDIOMYOPATHY DILATED HYPERTROPHIC RESTRICTIVE Fatigue, Exertional Dyspnea, fatigue weakness, dyspnea, fatigue, palpitations, angina, syncope, HF: MANAGEMENT dyspnea palpitations Bedrest Diuretics Cardiomegaly Cardiomegaly Cardiomegaly O2 management Moderate to Mild to moderate Mild Inotropic drugs severe Vasodilators Antiembolism stockings Decreased Increased/decrea Normal/Decreas ECG contractility sed contractility ed contractility Echocardiogram BNP Mitral valve Mitral valve AV valves CXR incompetence incompetence incompetence PAP Sinus Atrial and ventricular dysrhythmias tachycardia, atrial and ventricular dysrhythmias ACUESTA, DE RAMOS, JAVIER, MAALA, NAVAL, QUIZA, RAMIREZ, RIBON, UMALI 8 of 26 The CNSC does not intend to substitute learning materials provided by the College and its faculty. Use at your own discretion.  NUR 141: ACUTE AND BIOLOGIC CRISIS MIDTERMS RELEASE-NUR141-BSN48 HTN CRISIS: MANAGEMENT Decreased Normal/decreased CO Hypertensive Emergency: CO Intravenous vasodilators No outflow Increased outflow No outflow tract ○ Sodium Nitroprusside (nipiride, nitropress) tract tract obstruction obstruction ○ Nicardipine HL (Cardene) obstruction ○ Fenoldam Mesylate (Corlopam) ○ Enalaprilat (Vasotec IV) ○ Nitroglycerin (Nitro-BID IV, tridil) CARDIOMYOPATHY: PATHOPHYSIOLOGY Immediate action, short-lived (minutes to 4 hours); considered as initial treatment Hypertensive Urgency: Fast-acting agents Loop diuretics, beta-blockers, ACE inhibitor, Ca agonists, alpha2-agonists e.g., guanfacine (Tenex) Hemodynamic monitoring CARDIOMYOPATHY: MANAGEMENT Low Na diet Placement of an ICD or pacemaker, IABP Physical activity limitation - increased pressure would worsen the condition Limit OFI, if congestion is observed ○ SIGNS OF CONGESTION: pulsus alterans (hallmark), dyspnea, crackles, S4 heart sounds ECG Echocardiogram Cardiac catheterization CXR Endomyocardial biopsy Left ventricular outflow tract surgery – removal of MV, chordae, papillary muscles (valve replacement) LVAD and heart transplantation HYPERTENSIVE CRISIS ACUESTA, DE RAMOS, JAVIER, MAALA, NAVAL, QUIZA, RAMIREZ, RIBON, UMALI 9 of 26 The CNSC does not intend to substitute learning materials provided by the College and its faculty. Use at your own discretion.  NUR 141: ACUTE AND BIOLOGIC CRISIS MIDTERMS RELEASE-NUR141-BSN48 OUTLINE A. Review of Renal System B. Acute and Chronic Renal Failure a. Renal Failure C. Assessment a. Subjective Data (Nursing History) b. Objective Data (Physical Assessment) c. Objective Data (Diagnostic Assessment) D. Nursing Diagnosis A critical regulator in blood volume and electrolyte E. Medical/Surgical Management imbalances a. Pharmacological Management b. Diet and Nutrition Management ACUTE AND CHRONIC RENAL FAILURE c. Complementary/Alternative Therapy F. Client Educations RENAL FAILURE G. Reporting & Documentation. When the kidneys don't function at all or function at a low capacity REVIEW OF RENAL SYSTEM Acute - less than 6 months Chronic - more than 6 months ACUTE KIDNEY INJURY (AKI) Aka ARF (Acute Renal Failure) Sudden or abrupt decline Within few hours or days May be reversible Age, chronic disease, ICU patients RIFLE, AKIN, KDIGO (SCr, UO, eGFR) CLASSIFICATIONS: 1. RIFLE -risk, injury, failure, loss of kidney function and end-stage kidney disease 2. AKIN - Acute Kidney Injury Network 3. KDIGO - kidney disease improving global outcomes CAUSES: 1. Prerenal - decreased blood flow NEPHRON ANATOMY 2. Intrarenal - direct damage to the kidney s 3. Postrenal - urine obstruction PHASES: a. Oliguric Phase - Manifest 1-7 days - Urine Output: 55 years) hemianopsia ○ Gender (male) ○ Race CAUSES OF AIS ○ Family hx Thrombosis ○ Prior hx of stroke ○ Warning sign: TIA Modifiable ○ Occurs often or after sleep ○ HTN ○ Atherosclerotic plaques ○ Atrial fibrillation ○ Most common type: Small artery ○ Hyperlipidemia thrombosis ○ Obesity Emboli ○ Smoking ○ Warning sign: TIA ○ Diabetes ○ Occurs suddenly, without any activity ○ Periodontal disease ○ Cardiogenic ○ Alcoholic Associated w/ cardiac dysrhythmias e.g ○ Oral contraception Atrial Fibrillation, RHD, DVT (middle ○ Cerebral aneurysm cerebral artery) ○ Cryptogenic CLINICAL MANIFESTATIONS No known cause Motor loss ○ Others ○ Hemiplegia, hemiparesis Illicit drug use, coagulopathies, ○ Flaccid paralysis migraines, spontaneous dissection of the ○ Ataxia carotid or vertebral arteries Communication loss ○ Dysarthria ACUESTA, DE RAMOS, JAVIER, MAALA, NAVAL, QUIZA, RAMIREZ, RIBON, UMALI 24 of 26 The CNSC does not intend to substitute learning materials provided by the College and its faculty. Use at your own discretion.  NUR 141: ACUTE AND BIOLOGIC CRISIS MIDTERMS RELEASE-NUR141-BSN48 ○ Dysphagia or aphasia ABG - assesses oxygenation and acid-base ○ Apraxia balance Perceptual disturbances and sensory loss ○ Paresthesia MANAGEMENT ○ Loss of peripheral vision Administration of Anticoagulant ○ Hemianopia Recombinant Tissue Plasminogen Activator (t-PA) - Impaired cognitive and psychological effects thrombolytic ○ Change in mental status Osmotic Diuretics - to remove excess fluid and ○ Learning capacity manage increased ICP ○ Limited attention span Antihypertensive ○ Difficulties in comprehension Statin meds - antilipidemics ○ Forgetfulness Hemicraniectomy Intubation with an endotracheal tube OTHER SIGNS AND SYMPTOMS Hemodynamic Monitoring (blood pressure, heart Seizure rate,..) Fever Oxygen Therapy Headache Sliding scale of Insulin - hyperglycemia is a risk Vomiting factor for brain injury Agnosia Referring to other HCT ASSESSMENT NURSING CONSIDERATION F.A.S.T Monitoring Bleeding ○ F - facial drooping ○ check for cbc, physical bleeding, ○ A - arm weakness hematoma ○ S - speech difficulty Neuro checks RTC (round-the-clock) ○ T - time to call for help VS monitoring esp. BP & Temp History and complete physical and neurologic CBG monitoring examination Patient Safety ○ fall precautions DIAGNOSTICS Turn every 2 hours with proper alignment and Cranial CT Scan - to detect bleeding or brain tissue watch for increased ICP damage ○ to prevent pressure ulcer and pressure 12-lead ECG - identifies cardiac arrhythmia that injury may cause embolic strokes Monitor bowel and bladder function Cranial MRI Elevation of the head of the bed to 30 degrees to Xenon-enhanced CT Scan - assesses cerebral assist the patient in handling oral secretions and blood flow decrease ICP PET Scan Passive ROM with extremities and preventing Cerebral Angiography - visualizes the brain's blood contractures vessels to detect blockages Health education about prevention and promoting Single-photon emission computed tomography self care (SPECT) Scan TRAUMATIC SPINAL CORD INJURY (TSCI) LABORATORY Refers to the damage of spinal cord resulting to CBC w/ platelet - evaluates infection, anemia, and trauma platelet levels Symptoms may include partial or complete loss of PT and PTT - measures blood clotting time sensory function or motor control of arms, legs Lipid Profile - high cholesterol levels may cause and/or body atherosclerosis CK-BB (Creatine Kinase) CLASSIFICATION OF TSCI - found in the brain tissue Complete - total loss of sensory and motor function - higher than normal value indicates stroke or below the level of injury brain injury FBS ACUESTA, DE RAMOS, JAVIER, MAALA, NAVAL, QUIZA, RAMIREZ, RIBON, UMALI 25 of 26 The CNSC does not intend to substitute learning materials provided by the College and its faculty. Use at your own discretion.  NUR 141: ACUTE AND BIOLOGIC CRISIS MIDTERMS RELEASE-NUR141-BSN48 Incomplete - partial loss of sensory and/or motor History of Present Illness (HPI) function, with some preserved function below the DIAGNOSTIC injury X-ray Examinations Tetraplegia/ Quadriplegia (below the neck) - Computed Tomography (CT) paralysis affecting all four limbs and torso, typically Magnetic Resonance Imaging (MRI) due to cervical spine injury ECG Paraplegia - below the waist; paralysis affecting the lower limbs and lower body, usually due to thoracic, COMPLICATION lumbar, or sacral spine injury. Spinal and Neurogenic Shock Venous Thromboembolism Pneumonia Autonomic Dysreflexia Pressure Injuries Infections MANAGEMENT Prevent further SCI ○ ImmoImmobilization ○ Stabilization ○ Control Of Life-threatening Injuries ○ Maintain Patient In An Extended Position Corticosteroid administration Oxygen Therapy Endotracheal Intubation Tractions Cervical Collar Halo Vest COMMON CAUSES OF TSCI Vehicular Accidents Falls Assaults Sports related Work-Related NURSING CONSIDERATIONS CLINICAL MANIFESTATIONS Prevent further SCI Neurologic Level Establish stabilization and mobilization Total sensory and motor paralysis Monitor any decrease in neurologic function Loss of bladder and bowel control Monitor VS Loss of sweating and vasomotor tone ○ IMPORTANT: BP and RR Marked reduction of BP Palpate lower abdomen for signs of urinary Reflexes are absent retention and overdistention of the bladder Respiratory Problem Test motor ability Acute respiratory failure WOF any s/sx of Shock (hypotension, tachypnea, Motor Loss tachycardia / “hypo-tachy-tachy”, diaphoresis, and Paraplegic decrease in temperature) Quadriplegic Prevent infection ASSESSMENT Detailed neurologic examination ACUESTA, DE RAMOS, JAVIER, MAALA, NAVAL, QUIZA, RAMIREZ, RIBON, UMALI 26 of 26 The CNSC does not intend to substitute learning materials provided by the College and its faculty. Use at your own discretion.