NCLEX QUESTIONS CI UGH NURS 4271Questions With Answers Tested And Verified Exam Solutions, Exams of Nursing

Download NCLEX QUESTIONS CI UGH NURS 4271Questions With Answers Tested And Verified Exam Solutions and more Exams Nursing in PDF only on Docsity! NCLEX QUESTIONS CI UGH NURS 4271Questions With Answers Tested And Verified Exam Solutions With Rationale GRADED A+ STROKE 1. A client is eating a soft diet while recovering from a stroke. The client reports food accumulating in the cheek of the affected side. What is the nurse’s best response? 1. “Let’s see if the dietitian can help. 2. “Let’s see if the speech-language pathologist can help.” 3. “Let’s advance your diet to solid food.” 4. “Next time you eat, try lifting your chin when you swallow.” Answer: B Rationale: The speech-language pathologist identifies strategies to prevent food from accumulating in the cheek of the affected side of a client recovering from a stroke. The correct technique to improve swallowing is the chin-tuck method; however, the speech pathologist will assist the client with tongue exercises that will help move the food bolus to the unaffected side. Solid food is not appropriate for the client with chewing and swallowing challenges. The dietitian consults with the health care team if the client has had weight loss problems, or if abnormal laboratory results indicate a nutritional deficit 2. A client has been admitted with a diagnosis of stroke (brain attack). The nurse suspects that the client has had a right hemisphere stroke because the client exhibits which symptoms? 1. Aphasia and cautiousness 2. Impulsiveness and smiling 3. Inability to discriminate words 4. Quick to anger and frustration Answer: B Rationale: Impulsiveness and smiling are symptoms indicative of a right hemisphere stroke. Aphasia, cautiousness, the inability to discriminate words, quick to anger, and frustrations are symptoms indicative of a left hemisphere stroke. 3. Which statements by a client or family member about preventing stroke indicate a need for further teaching by the nurse? Select all that apply. 1. “I will adjust my aspirin drug dose depending on whether I have pain.” 2. “I have cut down on smoking to only a half-pack daily.” 3. “I need to walk at least 30 minutes most days of the week.” 4. “I need to consider salt content in the foods I eat at restaurants.” 5. “I don’t need to worry about fat calories in what I eat—my heart is fine!” Answer: A, B, E Rationale: Aspirin is prescribed in a fixed, low dose to prevent platelet activation and thrombus formation (ischemic stroke), not pain. Although decreasing smoking is helpful, the goal is smoking cessation. Stroke and cardiac risk are intertwined; fat calories contribute to atherosclerosis and stroke risk. Reducing salt intake and completing 30 minutes of walking daily decrease the risk for stroke. 4. Which are risk factors for stroke? Select all that apply. 1. High blood pressure 2. Previous stroke or TIA 3. Smoking 4. Use of oral contraceptives 5. Female gender Answer: A, B, C, D Rationale: Common modifiable risk factors for developing a stroke include smoking and the use of oral contraceptives, specifically in women over the age of 35 and in women over the age of 30 who smoke. Other risk factors include high blood pressure and history of a previous TIA. Gender is not a known risk factor for stroke; however, the female client is at risk for delayed recognition of early stroke symptoms. 5. A client has had a traumatic brain injury and is mechanically ventilated. Which technique does the nurse use to prevent increasing intracranial pressure (ICP)? 1. Assessing for Turner’s sign 2. Maintaining PaCO2 levels at 35 mm Hg 3. Placing the client in the Trendelenburg position 4. Suctioning the client frequently Answer: B Rationale: After the first 24 hours when a client is mechanically ventilated, keeping the PaCO2 levels at 35 mm Hg prevents vasodilation, which could increase ICP. CO2 is a powerful vasodilator. Turner’s sign is a bluish gray discoloration in the flank region caused by acute pancreatitis. The head of the bed should be at 30 degrees; the Trendelenburg position will cause the client’s ICP to increase. Although some suctioning is necessary, frequent suctioning should be avoided because it increases ICP. 6. Which modifiable risk factors for stroke would be most important for the nurse to include when planning a community education program? A. Hypertension B. Hyerlipidemia C. Alcohol consumption D. Oral contraceptive use Answer: A Rationale: Hypertension is the single most important modifiable risk factor, but it is still often undetected and inadequately treated. The public is often more aware of hyperlipidemia and oral contraceptive use as risk factors for stroke. Alcohol is also a modifiable risk factor. Rationale: Although all the symptoms should prompt further assessment by the nurse, dizziness, ataxia, diplopia, and lethargy are signs of hydration toxicity and should be reported. 4. Which characteristic of a patient’s recent seizure is consistent with a partial seizure? A. The patient lost consciousness during the seizure B. The seizure involved lip smacking and repetitive movements C. The patient fell to the ground and became still for 20 seconds D. The etiology of the seizure involved both sides of the patient’s brain Answer: B Rationale: The most common complex partial seizure involves lip smacking and automatisms (repetitive movements that may not be appropriate). Loss of consciousness, bilateral brain involvement, and a tonic phase are associated with generalized seizure activity. 5. A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this clients plan of care? A. Have suction equipment available B. Place a padded tongue blade at the bedside C. Permit only clear oral fluids D. Keep bed rails up at all times E. Maintain the client on strict bed rest F. Ensure that the client has IV access Answer: A, D, F Rationale: Oxygen and suctioning equipment with an airway must be readily available. The bed rails should be up at all times while the client is in the bed to prevent injury from a fall. If the client does not have an IV access, insert a saline lock, especially for those clients who are at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure. 1. A client with a history of seizures is placed on seizure precautions. Which emergency equipment will the nurse provide at the bedside? Select all that apply. A. Padded tongue blade B. intravenous Access C. Continuous Sedation D. Suction equipment at the bedside E. Siderails up Answer: B, D, E Rationale: Bite blocks or padded tongue blades should not be used because the client's jaw may clench, causing teeth to break and possibly obstructing the airway. 2. The nurse is caring for a client diagnosed with partial seizures after encephalitis, who is to receive carbamazepine (Tegretol). The nurse plans to monitor the client for which adverse effects? A. Headaches B. Dizziness C. Diplopia D. Increased blood glucose E. Alopecia Answer: A, B, C Rationale: Adverse effects the nurse must monitor for in a client taking carbamazepine for partial seizures after encephalitis include: headaches, dizziness, and diplopia. Carbamazepine affects the central nervous system, although it’s mechanism of action is unclear. Carbamazepine does not cause alopecia and does not increase blood glucose. Divalproex (Depakote) and valproic acid (Depakene) may cause alopecia. 3. The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do next? A. Documents the length and time of the seizure. B. Forces a tongue blade in the mouth. C. Positions the client on the side. E. Restrains the client. Answer: C Rationale: When a newly admitted client with a history of seizures begins to seize, the nurse must turn the client on his/her side. Turning the client on the side during a generalized tonic–clonic or complex partial seizure is indicated because he or she may lose consciousness resulting in potential loss of a patent airway. Documenting the length and time of seizures is important, but not the priority intervention. Both forcing a tongue blade in the mouth and restraining the client can cause injury. 4. You’re assessing your patient load for the patients who are at MOST risk for seizures. Select all the patients below that are most at risk: A. A 32-year-old with a blood glucose of 20 mg/dL. B. A 63-year-old whose CT scan shows an ischemic stroke. C. A 72-year-old who is post opt day 5 from open heart surgery. D. A 16-year-old with bacterial meningitis. E. A 58-year-old experiencing ETOH withdrawal. Answer: A, B, D, E Rationale: All the patients are at risk except option C. Remember all the risk factors: illness (especially CNS types like bacterial meningitis), fever, electrolyte/metabolic issues (low blood sugar, acidosis etc), ETOH (alcohol) withdraw, brain injury, STROKE, congenital brain defects, tumors etc. 5. The nurse has received report on a group of clients. Which client requires the nurse’s attention first? A. Adult who is lethargic after a generalized tonic–clonic seizure B. Young adult who has experienced four tonic–clonic seizures within the past 30 minutes C. Middle-aged adult with absence seizures who is staring at a wall and does not respond to questions D. Older adult with a seizure disorder who has a temperature of 101.9° F (38.8° C) Answer: B Rationale: After receiving report on a group of clients, the nurse first needs to attend to the young adult client who is experiencing repeated seizures over the course of 30 minutes. This client is in status epilepticus, which is a medical emergency and requires immediate intervention. The adult client who is lethargic and the middle- aged adult client with absence seizures do not require immediate attention. A fever of 101.9° F (38.8° C), although high, does not require immediate attention. SPINAL CORD INJURY 1. A patient with a spinal cord injury (SCI) is admitted to the unit and placed in traction. Which of the following actions is the nurse responsible for when caring for this patient? (Select all that apply) 2. A. modifying the traction weights as needed 3. B. assessing the patient's skin integrity 4. C. applying the traction upon admission 5. D. administering pain medication 6. E. providing passive range of motion Answer: B, D, E Rationale: The healthcare provider is responsible for initial applying of the traction device. The weights on the traction device must not be changed without the order of a healthcare provider. When caring for a patient in traction, the nurse is responsible for assessment and care of the skin due to the increased risk of skin breakdown. The patient in traction is likely to experience pain and the nurse is responsible for assessing this pain and administering the appropriate analgesic as ordered. Passive range of motion helps prevent contractures; this is often performed by a physical therapist or a nurse. 7. Which patient is at highest risk for a spinal cord injury? Answer: B, E, F Rationale: Autonomic dysreflexia can be caused by kinked catheter tubing allowing the bladder to become full, triggering massive vasoconstriction below the injury site, producing the manifestations of this process. Acute symptoms of autonomic dysreflexia, including a sustained elevated blood pressure, may indicate fecal impaction and pressure ulcer. The other answers will not cause autonomic dysreflexia 3. An unconscious patient receiving emergency care following an automobile crash accident has a possible spinal cord injury. What guidelines for emergency care will be followed? Select all that apply A. Immobilize the neck using rolled towels or a cervical collar. B. The patient will be placed in a supine position C. The patient will be placed on a ventilator. D. The head of the bed will be elevated. E. The patient's head will be secured with a belt or tape secured to the stretcher. Answer: A, B, E Rationale: In the emergency setting, all patients who have sustained a trauma to the head or spine, or are unconscious should be treated as though they have a spinal cord injury. Immobilizing the neck, maintaining a supine position and securing the patient's head to prevent movement are all basic guidelines of emergency care. Placement on the ventilator and raising the head of the bed will be considered after admittance to the hospital. 5. One indication for surgical therapy of the patient with a spinal cord injury is when? A.There is incomplete cord lesion involvement B. the ligaments that support the spine are torn C. a high cervical injury causes loss of respiratory function D. evidence of continued compression of the cord is apparent Answer: D Rationale: Although surgical treatment of spinal cord injuries often depends on the preference of the health care provider, surgery is usually indicated when there is continued compression of the cord by extrinsic forces or when there is evidence of cord compression. Other indications may include progressive neurologic deficit, compound fracture of the vertebra, bony fragments, and penetrating wounds of the cord. 6. During assessment of a patient with a spinal cord injury, the nurse determines that the patient has a poor cough with diaphragmatic breathing. Based on this finding, the nurses' first action should be to? A. initiate frequent turning and repositioning B. use tracheal suctioning to remove secretions C. assess lung sounds and respiratory rate and depth D. prepare the patient for endotracheal intubation and mechanical ventilation Answer: C Rationale: Because pneumonia and atelectasis are potential problems RT ineffective coughing function, the nurse should assess the patient's breath sound and resp function to determine whether secretions are being retained or whether there is progression of resp impairment. Suctioning is not indicated unless lung sounds indicate retained secretions: position changes will help mobilize secretions. Intubation and mechanical ventilation are used if the patient becomes exhausted from labored breathing or if ABGs deteriorate MULTIPLE SCLEROSIS 1. The healthcare provider is teaching a group of patients diagnosed with multiple sclerosis (MS) about common bladder problems. Which of the following will the healthcare provider include? Select all that apply: A. “Drinking caffeinated beverages can help you empty your bladder completely.” B. “Drinking lots of citrus juices will decrease the amount of bacteria in your urinary tract.” C. “MS may cause the bladder to contract and empty more often than usual.” D. “Drink 1.5 - 2 liters of water each day so your urine isn't too concentrated.” E. “You should not attempt to urinate until you feel that your bladder is full.” F. “Patients with MS are at increased risk of developing urinary tract infections.” Answer: C, D, E Rationale: • MS can cause a variety of urinary problems including detrusor over activity. Caffeinated beverages and alcohol are bladder irritants and should be limited or avoided. • Although citrus juices are acidic, they make urine more alkaline, which increases the risk of a urinary tract infection. • Drinking at least 1.5 - 2 liters of water each day will keep urine dilute. This will decrease bladder irritation. • MS heightens a patient's risk of urinary tract infections. Patients should plan to void on a regular basis. Voiding at least every 2 hours will decrease urine stasis. 2. A patient diagnosed with multiple sclerosis (MS) is admitted to the medical unit. When assessing the patient, which of the following will the healthcare expect to identify? Choose all answers that apply: A. Nystagmus B. Resting tremors C. Flaccid paralysis D. Scanning speech E. Seizures Answer: A, D Rationale: MS is an autoimmune inflammatory demyelinating disease of the brain and spinal cord. The tremor will be characterized by rhythmic shaking in the hands and/or arms during purposeful movement. Common findings can be remembered as the Charcot triad: nystagmus (and/or double vision), scanning speech (slow, hesitant pronunciation of words as syllables), and intention tremor. 3. When assessing the client with multiple sclerosis for potential complications of the disease, the nurse should asses the client for which symptoms? Select all that apply. A. Dehydration B. Falls C. Seizures D. Skin breakdown E. Fatigue Answer: B, D, E Rationale: The client with multiple sclerosis is at risk for falls due to muscle weakness, skin breakdown due to bowel and bladder incontinence, and fatigue. The client is not a risk for dehydration; seizures are not associated with myelin destruction. 4. Which information should the nurse include in the discharge plan for client with multiple sclerosis who has an impaired peripheral sensation? Select all that apply. Answer:D Rationale: An individualized exercise program is helpful in managing symptoms of MS. Problems such as motor weakness, spasticity, fatigue, poor balance, heat sensitivity are concerns that must be addressed when planning an exercise program. Swimming or water exercise is beneficial for patients diagnosed with MS because of the cooling effects of water. Exercise programs should be individualized in accordance with the patient’s symptoms and 5. The healthcare provider is planning care for a patient diagnosed with multiple sclerosis (MS). Which of the following is the priority intervention? A. Encourage bed rest in order to conserve strength B. Teach the patient’s family how to meet the patient’s need C. Monitor the patient’s temperature to avoid overheating D. Advise the patient to drink liquids through a straw Answer: D Rationale: Problems related to dysphagia (such as aspiration) can be minimized if the patient drinks liquids through a straw. Sensitivity to heat is concern with MS, but monitoring the patient’s temperature is not necessary MUSCULAR DYSTROPHY 1. The parents of a preschooler diagnosed with muscular dystrophy are asking questions about the course of their child's disease. The nurse should tell them which of the following? A. Muscular dystrophies are disorders associated with progressive degeneration of muscles, resulting in relentless and increasing weakness. B. The weakness that the child is currently experiencing will probably not increase. C. The child will be able to function normally and require no special accommodations. D. The extent of degeneration depends on performing daily physical therapy Answer: A Rationale: Muscular dystrophies are progressive degenerative disorders. The most common is Duchenne muscular dystrophy, which is an X-linked recessive disorder. 2. The nurse is teaching the parents of a child with Duchenne (pseudohypertrophic) muscular dystrophy. The nurse should tell them that some of the progressive complications include which of the following? A. Dry skin and hair, hirsutism, protruding tongue, and mental retardation. B. Anorexia, gingival hyperplasia, and dry skin and hair. C. Contractures, obesity, and pulmonary infections. D. Trembling, frequent loss of consciousness, and slurred speech. Answer: C Rationale: The major complications of muscular dystrophy include contractures, disuse atrophy, infections, obesity, respiratory complications, and cardiopulmonary problems. 3. The Gower sign for assessing Duchenne muscular dystrophy can be elicited by having a patient do which of the following? A. Close the eyes and touch the nose with alternating index fingers. B. Hop on one foot and then the other. C. Bend from the waist to touch the toes. D. Walk like a duck and rise from a squatting position. Answer: D Rationale:Children with muscular dystrophy display the Gower sign, which is great difficulty rising and standing from a squatting position due to the lack of muscle strength. 4. A 5-year-old has been diagnosed with Duchenne (pseudohypertrophic) muscular dystrophy. Which of the following nursing interventions would be appropriate? A. Discuss with the parents the potential need for respiratory support. B. Explain that this disease is easily treated with medication. C. Suggest exercises that will limit the use of muscles and prevent fatigue. D. Assist the parents in finding a nursing facility for future care Answer: A Rationale: Muscles become weaker, including those needed for respiration, and a decision will need to be made about whether respiratory support will be provided. 5. The mother of a child with Duchenne muscular dystrophy asks the nurse who in the family should have genetic screening. Who should the nurse say must be tested? Select all that apply. A. The mother and father. B. The sister. C. The brother. D. The aunts and all female cousins. E. The uncles and all male cousins. Answer: A, B, D Rationale: Genetic counseling is important in all inherited diseases. Duchenne muscular dystrophy is inherited as an X-linked recessive trait, meaning the defect is on the X chromosome. Women carry the disease, and males are affected. All female relatives should be tested. B. Women carry the disease, and males are affected. All female relatives should be tested. D. Women carry the disease, and males are affected. All female relatives should be tested TEST-TAKING HINT: Knowing that Duchenne muscular dystrophy is inherited as a X- linked trait excludes brother, uncle, and male cousins as carriers. 1. A child was diagnosed with Duchenne’s muscular dystrophy, which of the following usually is the first indication of the condition? A. Inability to suck in the newborn B. Lateness in walking in the toddler C. Difficulty running in the preschooler D. Decreasing coordination in the school-aged child C Usually signs and symptoms of Duchenne’s muscular dystrophy are not noticed until ages 3 to 5 years. Typically, weakness starts with the pelvic girdle. 2. In Duchenne’s muscular dystrophy, genetic testing can? Select all that apply A. Confirm a diagnosis B. Identify the genetic mutation C. Assist with family planning D. Stop the disease if found early enough A.B,C All those answers are true about DMD. Genetic testing is a simple blood test that can confirm a diagnosis of the disease. If a diagnosis is confirmed it will identify the genetic mutation and allow the family to plan appropriately for the future 3. A 4 year old boy is diagnosed with Duchenne muscular dystrophy. Which teaching is most appropriate for this child? A. Increase intake of foods high in iron B. Lift weights to strengthen weak muscles C. Remove throw rugs D. Take the muscle relaxant baclofen on time each day C Muscular dystrophy is the most common form of childhood MD. The muscles of the proximal lower extremities and pelvis are affected first. Most children are wheelchair bound so it is important to avoid floor clutter and prevent falls/injury. A child has recently been diagnosed with Duchenne’s muscular dystrophy. The parents are receiving genetic counseling prior to planning another pregnancy. Which of the following statements includes the most accurate information? A. Duchenne’s is an X-linked recessive disorder, so daughters have a 50% chance of being carriers and sons have a 50% chance of developing the disease. B. Duchenne’s is an X-linked recessive disorder so both daughters and sons have a 50% chance of developing the disease. C. Each child has 1 in 4 (25%) chance of developing the disorder. D. Sons only have a 1 in 4 (25%) chance of developing the disorder. A Rationale: While assessing the current condition, the nurse should ask about bowel changes, as clients with PD face problems with peristalsis, which contributes to constipation. The client may also have cognitive deficits such as memory loss, slowed thinking, and confusion, which eventually progress to dementia. Another aspect that needs to be assessed is responses to medication, especially for "on-off" or "wearing off" effects that indicate that medication is losing its effectiveness. Clients with PD have difficult falling and staying asleep, so difficulty in waking up is not related. Postural hypotension is common in Parkinson disease, resulting in blood pressure that drops when the client stands up, not while sitting. 1.A patient who is diagnosed with Parkinson disease (PD) states, “I can’t tie my shoelaces anymore.” The healthcare provider recognizes that this patient’s problem is due to a deficiency in which of these neurotransmitters? A. Norepinephrine B. Dopamine C. Glutamate D. Serotonin Answer: B Rationale: Dopamine is responsible for regulated body movements. People who have a dopamine deficiency will experience difficulty with motor function and purposeful movement 2. When planning care for a patient diagnosed with Parkinson disease, which of these patient outcomes should receive priority in the patient’s plan of care? A. Taking a daily walk around the neighborhood B. Taking a vitamin supplement C. Working on a favorite hobby D. Toileting and bathing independently Answer: D Rationale: Having the patient be able to do their ADL’s on their own promotes independence and is the top priority to the patient’s self care 3. A patient, who has been prescribed the antiparkinsonian medication carbidopa/levodopa, asks the healthcare provider, “Why am I getting these two medications?” How should the healthcare provider respond A. The carbidopa prevents the breakdown of levodopa B. These two together will prevent side effects C. The levodopa turns carbidopa into dopamine when it reaches the brain D. This drug combination is composed of two of the same medications Answer: A Rationale: Levodopa is converted into dopamine in the brain, while carbidopa helps to prevent the rapid breakdown of it, allowing it to remain a useful neurotransmitter in the brain for a longer period of time 4. A patient with a diagnosis of Parkinson’s disease is admitted to the medical unit. Which of these menu options is the safest choice for this patient? A. Raw vegetables B. Milkshake C. Chicken broth D. Sandwich Answer: B Rationale: Most PD patients experience dysphagia as the disease progresses. In this case, a thick substance is needed to make swallowing easier. Vegetables and a sandwich create a choking hazard and broth is too thin 5. Which of the following interventions will the healthcare provider put in place when caring for a patient who has been diagnosed with Parkinson disease (PD)? Select all that apply. A. Insert an indwelling catheter 6. Assist the patient with ambulation 7. Provide a clear liquid diet 8. Administer a stool softener 9. Auscultate lung sounds Answer: B, D, E Rationale: Patients experience constipation, difficulty ambulating/ walking, and often times are stagnant for long periods of time, requiring lung sounds to be auscultated. PT’s should never have a catheter or be on a CLD unless specified by a HCP LUPUS 1. The client enters the outpatient clinic and states to the triage nurse, "I think I have the flu. I'm so tired, I have no appetite, and everything hurts." The triage nurse assesses the client and finds a butterfly rash over the bridge of nose and on the cheeks. Which diagnosis does the nurse expect? A) Systemic lupus erythematosus B) Fibromyalgia C) Lyme disease D) Gout Answer: A Rationale: The rash over the nose and cheeks is sometimes called a butterfly rash and is classic for the diagnosis of systemic lupus erythematosus (SLE), although not every client diagnosed with this disorder will have this rash. While fibromyalgia, Lyme's disease, and gout share some symptoms of SLE, they do not cause a rash over the nose and cheeks. 2. A female client asks the nurse if there are any conditions that can exacerbate systemic lupus erythematosus (SLE). Which is the best nurse response? A) "Conditions that cause hypotension can often exacerbate SLE." B) "GI upset is often associated with SLE exacerbation." C) "Pregnancy is often associated with an SLE exacerbation." D) "Fever is a known trigger for an SLE exacerbation." Answer: C Rationale: Pregnancy can be associated with an exacerbation of SLE due to the rise of estrogen levels. Hypotension, fever, and GI upset are not factors that risk exacerbation of SLE. 3. A client with SLE is being treated with immunosuppressant drugs and corticosteroids. Which precautions should the nurse provide this client? Select all that apply. A) Avoid large crowds. B) Don't get a flu shot. C) Use contraception to prevent pregnancy D) Refrain from taking aspirin or ibuprofen. E) Report signs of infection to the physician. Answer: A, C, D, E Rationale: Crowds may increase exposure to infection. Annual influenza vaccination is recommended but clients with significant immunosuppression should not receive live vaccines. Immunosuppressive drugs may increase the risk of birth defects. Aspirin or ibuprofen may increase the risk of bleeding. Chills, fever, sore throat, fatigue, or malaise should be reported. 4. The nurse is caring for a client who has been diagnosed with discoid lupus erythematosus. The nurse is collaborating with the client to set goals for the nursing plan of care. What is an appropriate goal for this client? A) Work through the stages of death and dying. B) Comply 100% of the time with a sun protection plan. C) Gain weight to within 10 pounds of normal for height. D) Report pain no higher than four on a scale of 1-10. Answer: B c) Avoid larger crowds d) Report signs of infection to your hcp e) Refrain from taking aspirin or ibuprofe Answer: A, C, D, E Rationale: The risk of being exposed to infection is increased in crowds. It is important to get your flu shot annually. But if a client is immunosuppressed they should not receive live vaccines. Immunosuppressive drugs may increase the risk of birth defects. Aspirin and or Ibuprofen may increase the risk of bleeding. Sore throat, fever, chill, or malaise should be reported. SICKLE CELL 1. A patient who is having a sickle cell crisis asks the nurse why the sickling causes such pain. The nurse explains that the pain of sickling is caused by A. Spasms of the blood cells as they change shape B. Deposition of sickled red cells in the bone marrow C. Tissue hypoxia caused by small blood vessel occlusion D. Infectious processes in organs affected by the sickling Answer: C Rationale: The pain associated with sickle cell crisis is caused by ischemia as the sickled cells occlude small blood vessels and capillaries. 2. Which of the following factors need(s) to be included in a teaching plan for a child with sickle cell anemia? Select all that apply. A. The child needs to be taken to a physician when sick. B. The parent should make sure the child sleeps in an air-conditioned room. C. Emotional stress should be avoided. D. It is important to keep the child well hydrated. Answer: A, C, D Rationale: A is correct because the parent should seek medical attention for illness to prevent the child from going into a crisis. C is correct because Stress can cause a depressed immune system, making the child more susceptible to infection and crisis. Parents and children are advised to avoid stress. D is correct because drinking water promotes healthy blood flow & reduces the chance of RBCs sickling and sticking together 3. An 18 year-old male is taking Hydroxyurea for treatment of sickle cell anemia. Which options below indicate this medication is working successfully? Select all that apply: A. The patient needs fewer blood transfusions B. The patient experiences diuresis C. The patient experiences an increase in fetal hemoglobin (Hbg F). D. The patient experiences a decrease in hemoglobin S. Answer: A, C Rationale: This medications actually treats cancer, but it will help with SCA in that it will help create fetal hemoglobin hgb F (this helps decrease sickling episodes) and helps with anemia (decreasing the need for so many blood transfusions). 4. You're providing education to a patient with sickle cell anemia who is taking Hydroxyurea. You will make it priority to tell the patient to? A. Consume foods high in calcium and potassium B. Avoid sick people and maintain strict hand hygiene C. Take this medication with at least 8 oz of water D. Monitor your blood glucose level daily Answer: B Rationale: This medication can lower the white blood cell count. Therefore, the nurse should make it priority to tell the patient to avoid infection by avoiding sick people and performing hand hygiene regularly. 5. A 14 year-old female has sickle cell anemia. Which factors below can increase the patient’s risk for developing sickle cell crisis? Select all that apply: A. Shellfish B. Infection C. Dehydration D. Hypoxia E. Low altitudes F. Hemorrhage G. Strenuous Exercise Answer: B, C, D, F, G Rationale: Sickle cell crisis can occur when the body experiences low amounts of oxygen in the body (so think about something that increases the body’s need for oxygen or affects how oxygen is being transported). Therefore, infection (especially respiratory infections), dehydration, hypoxia, HIGH (not low) altitudes, hemorrhage (blood loss), or strenuous exercise can lead to a sickle cell crisis 1. The clinic nurse instructs parents of a child with sickle cell anemia about the precipitating factors related to sickle cell crisis. Which, if identified by the parents as a precipitating factor, indicates the need for further instruction? A. Stress B. Trauma C. Infection D. Fluid Overload Answer: D Rationale: Sickle cell crises are acute exacerbations of the disease, which vary considerably in severity and frequency, these include vaso-occlusive crisis, splenic sequestration, hyper hemolytic crisis, and aplastic crisis. Sickle cell crisis may ne precipitated by infection, dehydration, hypoxia, trauma, or physical or emotional stress. The mother of a child with sickle cell disease should encourage fluid intake of 1 ½ to 2 times the daily requirement to prevent dehydration. 2. The nurse is reviewing a health care provider’s prescriptions for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso- occlusive crisis. Which prescriptions documented in the child’s record should the nurse question? Select all that apply. A. Restrict fluid intake B. Position for comfort C. Avoid strain on painful joints D. Apply nasal oxygen at 2 L/minute E. Provide a high-calorie, high-protein diet F. Give meperidine, 25mg intravenously, every 4 hours for pain Answer: A, F Rationale: Sickle cell anemia is one of a group of diseases termed hemoglobinopathies, in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. It is caused by the inheritance of a gene for aa structurally abnormal portion of the hemoglobin chain. Hemoglobin S is sensitive to changes in the oxygen content of the red blood cell; insufficient oxygen causes the cells to assume a sickle shape, and the cells become rigid and clumped together, obstructing capillary blood flow. Oral and intravenous fluids are an important part of treatment. Meperidine is not recommended for a child with sickle cell disease because of the risk for normeperidine-induced seizures. Positioning for comfort, avoiding strain on painful joints, oxygen, and a high-calorie and high-protein diet are also important parts of the treatment plan. 3. The nurse is preparing a client with sickle cell anemia for discharge. What information should the nurse include in the teaching plan? Select all that apply. A. Drink plenty of fluids when outside in the hot weather B. Avoid being in high altitudes where less oxygen is available C. Be aware that since she is homozygous for HbS, she carries the sickle cell trait D. Know that pregnancy with sickle cell disease increases the risk of a crisis E. Avoid flying on commercial airlines Answer: A, B, D into the joint continues, the area becomes hot, swollen, and immobile—not cool, pale, and clammy. Ecchymosis formation around a joint would be difficult to assess. Instability of a long bone on passive movement is not associated with joint hemarthrosis. 5. A pediatric nurse health educator provides a teaching session to the nursing staff regarding hemophilia. Which of the following information regarding this disorder would the nurse plan to include in the discussion? A. Hemophilia is a Y linked heredity disorder B. Males inherit hemophilia from their fathers C. Females inherit hemophilia from their mothers D. Hemophilia A results from a deficiency of factor VIII Answer: D Rationale: Males inherit hemophilia from their mothers, and females inherit the carrier status from their fathers. Hemophilia is inherited in a recessive manner via a genetic defect on the X-chromosome. Hemophilia A results from a deficiency of factor VIII. Hemophilia B (Christmas disease) is a deficiency of factor IX. 1. The healthcare provider is caring for a child who has been diagnosed with hemophilia A. Which of the following laboratory results will be expected? Choose all that apply. A. Decreased hematocrit B. Prolonged prothrombin time (PT) C. Decreased fibrinogen D. Prolonged activated partial thromboplastin time (aPTT) E. Normal platelet count Answer: D, E Rationale: Of the laboratory results given, the only expected results are normal platelet counts and prolonged activated partial thromboplastin time (aPTT). ▪ Hemophilia A results in a deficiency of factor VIII. ▪ Coagulation is adversely affected, but not platelets or red blood cells. ▪ Fibrinogen is a precursor to fibrin. Its made in the liver and circulates in the blood. It is not affected by a deficiency of Factor VIII, but since the coagulation cascade is adversely affected, fibrin formation in impaired. ▪ Factor VIII is part of the intrinsic pathway, so the aPTT will be prolonged. 2. A pediatric nurse health educator provides a teaching session to the nursing staff regarding hemophilia. Which of the following information regarding this disorder would the nurse plan to include in the discussion? A. Hemophilia is a Y linked hereditary disorder B. Males inherit hemophilia from their fathers C. Females inherit hemophilia from their mothers D. Hemophilia A results from a deficiency of factor VIII Answer: D Rationale: Males inherit hemophilia from their mothers, and females inherit the carrier status from their fathers. Hemophilia is inherited in a recessive manner via a genetic defect on the X-chromosome. Hemophilia A results from a deficiency of factor VIII. Hemophilia B (Christmas disease) is a deficiency of factor IX. 3. Which of the following assessments in a child with hemophilia would lead the nurse to suspect early hemarthrosis? A. Child's reluctance to move a body part B. Cool, pale, clammy extremity C. Ecchymosis formation around a joint D. Instability of a long bone in passive movement Answer: A Rationale: Bleeding into the joints in the child with hemophilia leads to pain and tenderness, resulting in restricted movement. Therefore, an early sign of hemarthrosis would be the child's reluctance to move a body part. If the bleeding into the joint continues, the area becomes hot, swollen, and immobile—not cool, pale, and clammy. Ecchymosis formation around a joint would be difficult to assess. Instability of a long bone on passive movement is not associated with joint hemarthrosis. 4. Mr. and Mrs. Smith’s child has hemophilia; which of the following actions would you instruct them to avoid? A. Immobilizing the joint B. Lowering the injured area C. Applying cold to the area D. Applying pressure Answer: B Rationale: With hemophilia, the injured area must be elevated, not lowered. Options A, C, and D: Immobilizing the joint and applying cold or pressure to the area are appropriate measures to control bleeding. 5. Which nursing interventions should the nurse implement when caring for a client diagnosed with hemophilia A? Select all that apply. A. Instruct the client to use a razor blade to shave. B. Avoid administering enemas to the client. C. Encourage participation in noncontact sports. D. Teach the client how to apply direct pressure if bleeding occurs. E. Explain the importance of not flossing the gums Answer: B, C, D Rationale: The client should use an electric razor, which minimizes the opportunity to develop superficial cuts that may result in bleeding. Enemas, rectal thermometers, and intramuscular injections can pose a risk of tissue and vascular trauma that can precipitate bleeding. Even minor trauma can lead to serious bleeding episodes; safer activities such as swimming or golf should be recommended. Direct pressure occludes bleeding vessels. There is no reason why the client can't floss the teeth. THALASSEMIA 1. The long-term complications seen in thalassemia major are associated to which of the following? A. Anemia B. Growth retardation C. Hemochromatosis D. Splenomegaly Answer: C Rationale: Long-term complications arise from hemochromatosis, excessive iron deposits precipitating in the tissues and causing destruction. A. 2. Which of the following is FALSE concerning Thalassemia? It is an inherited blood disorder characterized by an abnormal production of hemoglobin B. It is a blood disorder that you acquire later in life and it affects hemoglobin C. A person with thalassemia will experience symptoms common to anemia D. You are at higher risk if you are from Mediterranean descent Answer: B Rationale: Thalassemia is an inherited disorder 3. Which type of thalassemia disease is Cooley anemia? A. Alpha- thalassemia B. Beta- thalassemia C. Alloimmunization D. None of the above Answer: B Rationale: Beta thalassemia is a major disease which causes serious illness and is also known as Cooley's Anaemia 5. A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with thoughts about dying. Do you think I am just being morbid?" Which response by the nurse is best? "Thinking about dying will not improve the course of AIDS.” B) "It is important to focus on the good things about your life now.” C) "Do you think that taking an antidepressant might be helpful to you?” D) "Can you tell me more about the kind of thoughts that you are having?" Asnwer: D Rationale: : Further assessment of the patient's psychosocial status is needed before taking any other action. The statements, "Thinking about dying will not improve the course of AIDS" and "It is important to focus on the good things in life" discourage the patient from sharing any further information with the nurse and decrease the nurse's ability to develop a trusting relationship with the patient. Although antidepressants may be helpful, the initial action should be further assessment of the patient's feelings. RA & OA 1. A patient is prescribed ibuprofen 800 mg every 4 hours for the treatment of rheumatoid arthritis (RA). Which of these clinical manifestations should the healthcare provider anticipate observing if the patient is developing an adverse effect from the medication? Select that apply: 1. Positive occult blood test 2. Increased blood urea nitrogen (BUN) 3. Client report epigastric pain 4. Decreased serum albumin 5. Increased serum hematocrit Answer: 1, 2, 3 • Rationale: A good place to start when assessing for medication adverse effects is to recall the medication’s mechanism of action. • NSAIDs like ibuprofen inhibit COX-1 and COX-2. • Inhibiting COX-1 and COX-2 results in decreased prostaglandins. • Pain is managed when COX-1 is inhibited. • COX-2 is sometimes referred to as “good COX” (while COX-1 is sometimes called “bad COX), because when COX-2 is inhibited, prostaglandins that serve important normal functions are impaired. Prostaglandins are needed for the integrity of the peptic mucosal lining and maintenance of renal perfusion. Epigastric pain (peptic ulcer), blood in the stool (bleeding ulcer), and increased BUN (decreased renal perfusion and increased reabsorption of blood from the GI tract) are all indications that the patient may be experiencing a bleeding peptic ulcer. 2. Which of the following clinical manifestations should the healthcare provider anticipate observing in a patient diagnosed with rheumatoid arthritis (RA)? Select all that apply: 1. Increase C-reactive protein (CRP) 2. Low grade fever 3. Decreased synovial fluid 4. Ulnar deviation 5. Bone spurs noted on X-ray Answer: 1, 2, 4 Rationale: Think about the differences between the two major types of arthritis: osteoarthritis (OA) and rheumatoid arthritis (RA), and how those differences affect clinical presentation. ● RA is an autoimmune disease, while OA is not. ● Inflammation is slight and localized in OA. ● RA has systemic effects, while OA does not. ● Clinical manifestations expected in RA include increased CRP (a general indication of inflammation), low-grade fever (a systemic manifestation), and ulnar deviation (caused by chronic synovial inflammation, weakened ligaments, and subsequent deformities). 3. During a routine health check-up visit a patient states, “I’ve been experiencing severe pain and stiffness in my joints lately.” As the nurse, you will ask the patient what questions to assess for other possible signs and symptom of rheumatoid arthritis? Select all that apply: 1. “Does the pain and stiffness tend to be the worst before bedtime?” 2. “Are you experiencing fatigue and fever as well?” 3. “Is your pain and stiffness symmetrical on the body?” 4. “Is your pain and stiffness aggravated by extreme temperature changes?” Answer: 2, 3 Rationale: Patients with RA will experience pain and stiffness in the morning (for more than 30 minutes) not bedtime. It is common for patients to have a fever and be fatigued…remember RA affects the whole body not just the joints. It will also affect the same joints on the opposite side of the body. Therefore, if the right wrist is inflamed, painful, and stiff the left wrist will be as well. RA is NOT aggravated by extreme temperatures. This is found in osteoarthritis. 4. True or False: Rheumatoid arthritis tends to affect women more than men and people who are over the age of 60. Answer: T Rationale: Yes, RA tends to affect women more than men BUT it can affect all agees, most commonly 20-60 years old. 5. You are providing education to a patient, who was recently diagnosed with rheumatoid arthritis, about physical exercise. Which statement made by the patient is correct? 1. “It is best I try to incorporate a moderate level of high impact exercises weekly into my routine, such as running and aerobics.” 2. “I will be sure to rest joints that are experiencing a flare-up, but I will try to maintain a weekly regime of range of motion exercises along with walking and riding a stationary bike.” 3. “It is important I perform range of motion exercises during joint flare- ups and incorporate low-impact exercises into my daily routine.” 4. “Physical exercise should be limited to only range of motion exercises to prevent further joint damage.” Answer: B Rationale: During flare-ups of RA the patient should rest the joint. However, it is important the patient performs range of motion exercises along with LOW-IMPACT exercise weekly (such as stationary bike riding, walking, water aerobics etc.). This will help with increasing the patient’s energy level along with muscle strength and maintain joint health. 6. Which patient below is presenting with signs and symptoms of rheumatoid arthritis? Select all that apply: 1. A 35 year old patient who has severe morning stiffness for 45 minutes. 2. A 45 year old male with crepitus in the right knee. 3. A 30 year old female with warm, red, soft joints on the hands and wrist. 4. A 40 year old male whose x-ray imaging results showed osteophytes formation and decreased joint space in the left knee. Answer: 1, 3 Rationale: Options 1 and 3 (morning stiffness, warm, red, soft joints) are common findings in RA. However, options 2 and 4 (crepitus, osteophytes formation and decreased joint space) are found in OA. 1. During a routine health check-up visit a patient states “I’ve been experiencing severe pain and stiffness in my joints lately.” As the nurse, you will ask the patient what questions to assess for other possible signs and symptoms of rheumatoid arthritis? Select all that apply A. Does the pain and stiffness tend to be the worst before bedtime B. Are you experiencing fatigue and fever as well? C. Is your pain and stiffness symmetrical on the body? D. Is your pain and stiffness aggravated by extreme temperatures changes? Answer: B, C