NCLEX- PN Practice Exam 2

EXPLANATION

✔Correct answer:

Cover both eyes and arrange for transport to the emergency room.  In cases where a metal fragment is lodged in the eye, the priority is to prevent further injury or displacement of the object until proper medical evaluation and treatment can be performed by an ophthalmologist or in an emergency room. Covering both eyes is crucial because eye movement in one eye triggers corresponding movement in the other eye (consensual movement). By covering both eyes, Nurse Laura reduces the risk of additional trauma to the affected eye caused by involuntary movement.

Attempting to remove the object or flushing the eye could worsen the injury, particularly if the object is embedded in sensitive eye structures such as the cornea or sclera. Immediate professional evaluation and treatment are essential to prevent complications such as perforation, infection, or vision loss.

Imagine the eye as a delicate camera lens with a small shard of glass stuck on its surface. If you try to remove the shard or shake the camera, you risk scratching or shattering the lens further. Instead, you carefully cover the lens to protect it from movement or additional damage and take the camera to a professional repair shop where it can be fixed safely and precisely. Similarly, covering both eyes immobilizes the injured one, preventing further harm, and ensures the client receives specialized care to preserve vision.

Nurse Laura should follow these steps to ensure Mr. Wilson’s safety while awaiting specialized care.

• Instruct the client to avoid touching or rubbing the affected eye to prevent further displacement of the metal fragment.
• Gently cover both eyes using a protective shield or a clean, rigid object (e.g., a paper cup) over the injured eye, along with a soft dressing over the other eye.
• Do not apply pressure to the injured eye while covering it, as this could worsen the injury.
• Arrange for immediate transport to an emergency room or ophthalmology specialist for evaluation and treatment.
• Monitor for signs of worsening injury, such as severe pain, excessive tearing, or changes in vision, and report them to the emergency team upon arrival.

✘Incorrect answer options:

Place a sterile 4×4 dressing over the right eye. While protecting the injured eye is essential, using only a dressing for one eye would still allow movement in the other eye, which could inadvertently cause further damage to the injured eye. Both eyes must be covered to immobilize the affected eye effectively.

Attempt to dislodge the metal fragment using a cotton-tipped applicator. Attempting to remove a foreign object, especially one embedded in the eye, can cause severe damage to delicate eye structures such as the cornea or sclera. Removal should only be performed by a trained medical professional using specialized equipment.

Flush the affected eye with running water for 10 minutes. Flushing is appropriate for chemical exposures or superficial debris, but it is contraindicated when a foreign object is embedded in the eye. Flushing could dislodge the object, potentially causing deeper penetration or additional damage.

EXPLANATION

✔Correct answer:

Lorazepam (Ativan).  Lorazepam (Ativan) is a benzodiazepine commonly used to manage alcohol withdrawal symptoms. Alcohol withdrawal can cause a range of symptoms, from mild anxiety and tremors to severe complications such as delirium tremens (DTs) and seizures. Benzodiazepines like lorazepam are effective because they enhance the action of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter, helping to reduce the hyperexcitability of the central nervous system caused by alcohol withdrawal.

Lorazepam is particularly preferred in alcohol withdrawal due to its:

• Sedative effects: It helps reduce anxiety, agitation, and tremors.
• Seizure prevention: It decreases the risk of alcohol withdrawal seizures.
• Shorter half-life: This makes it safer for patients with impaired liver function, which is common in chronic alcohol use.

The Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-Ar) is often used to guide benzodiazepine dosing, ensuring that symptoms are managed effectively while avoiding over-sedation.

Think of lorazepam as a "shock absorber" for the brain. When alcohol is suddenly removed, the brain becomes overly excited, like a car bouncing uncontrollably. Lorazepam smooths out the ride by calming the brain's overactivity.

Nurse Sarah should closely monitor Mr. Jones for withdrawal symptoms and adverse effects of the treatment.

• Perform regular assessments using the CIWA-Ar scale to evaluate the severity of withdrawal symptoms and guide lorazepam administration.
• Monitor for signs of over-sedation, respiratory depression, or hypotension, which can occur with benzodiazepine use.
• Ensure a calm, quiet environment to reduce external stimuli that could exacerbate withdrawal symptoms.
• Educate the patient about the importance of continued treatment for alcohol dependence, including relapse prevention strategies and counseling.
• Encourage hydration and nutrition to address deficits caused by chronic alcohol use and withdrawal.

✘Incorrect answer options:

Disulfiram (Antabuse). Disulfiram is not used to manage acute alcohol withdrawal. Instead, it is prescribed for alcohol abstinence after detoxification by creating an unpleasant reaction (nausea, vomiting, flushing) if alcohol is consumed.

Flumazenil (Romazicon). Flumazenil is a benzodiazepine antagonist used to reverse benzodiazepine overdose or sedation. It is not indicated for alcohol withdrawal and could worsen symptoms by antagonizing the effects of benzodiazepines used in treatment.

Methadone (Dolophine). Methadone is an opioid agonist used to manage opioid withdrawal and chronic pain. It is not effective for treating alcohol withdrawal symptoms, as the underlying pathophysiology and treatment mechanisms differ.

EXPLANATION

✔Correct answer:

To ensure the infection has resolved completely.  The primary reason for a follow-up appointment after treating otitis media is to ensure that the infection has resolved completely. In toddlers like Sophie, otitis media can lead to complications such as persistent fluid in the middle ear (otitis media with effusion) or recurrent infections if not fully treated. This follow-up visit allows the healthcare provider to assess the status of the ear using an otoscope to check for lingering inflammation, fluid, or structural issues in the ear.

Ensuring complete resolution of the infection is particularly critical in young children because persistent or untreated otitis media can lead to complications such as:

• Hearing loss, which can impact speech and language development.
• Chronic or recurrent infections, which may require more aggressive treatment.
• Rare but serious complications, such as mastoiditis.

Think of treating otitis media like fixing a leak in a pipe. Even if the leak appears stopped, you need to recheck to ensure no residual water (fluid) is left to cause future problems, like rust or mold.

Nurse Jenna should educate Sophie’s parents about the importance of the follow-up visit and provide related guidance.

• Encourage the parents to schedule the follow-up appointment approximately 2 weeks after completing antibiotics, as residual fluid may persist temporarily but should clear over time.
• Educate parents to monitor for signs of persistent or recurrent infection, such as fever, ear tugging, irritability, or fluid drainage from the ear, and report these symptoms promptly.
• Discuss the potential impact of untreated ear infections on hearing and language development to reinforce the importance of the follow-up visit.
• Advise parents to complete the full course of antibiotics as prescribed, even if symptoms improve before the medication is finished.
• Provide resources for managing pain or discomfort, such as acetaminophen or ibuprofen, if symptoms persist during the recovery period.

✘Incorrect answer options:

To evaluate if the ear infection has impacted her hearing. While hearing evaluation is important in children with recurrent or severe otitis media, it is not the primary purpose of this specific follow-up visit. The focus is on ensuring the infection is resolved. Hearing tests may be scheduled later if there is evidence of persistent fluid or developmental concerns.

To confirm that all the antibiotics were taken as prescribed. Confirming adherence to the antibiotic regimen is important, but it is not the main reason for the follow-up visit. The primary goal is to verify the infection has resolved, regardless of whether antibiotics were taken correctly.

To prepare a new prescription in case of recurrence. While recurrence is possible, the follow-up visit is aimed at evaluating the current infection’s resolution rather than automatically preparing for a future issue. Additional antibiotics are only prescribed if there is evidence of persistent or recurrent infection.

EXPLANATION

✔Correct answer:

To encourage flexion of the artificial joint.  The primary purpose of a continuous passive motion (CPM) machine after a total knee replacement is to encourage flexion and extension of the artificial joint to promote joint mobility, prevent stiffness, and aid in the recovery of the knee’s range of motion. The CPM machine gently and continuously moves the knee joint through a prescribed range of motion, which helps reduce swelling, improve circulation, and prevent adhesions or scar tissue formation in the joint.

By initiating early passive movement, the CPM machine allows Mrs. Adams to regain flexibility in her knee without requiring active effort, which is particularly important in the immediate post-operative period when pain and stiffness are common.

Think of the CPM machine like a "gentle stretching assistant" that keeps the knee joint moving, preventing it from becoming stiff, much like stretching out a rubber band so it doesn’t lose its elasticity.

Nurse Taylor should ensure that the CPM machine is set up properly and that Mrs. Adams receives appropriate education and monitoring to maximize its benefits.

• Set the CPM machine to the prescribed range of motion, usually beginning with a low degree of flexion and gradually increasing as tolerated.
• Ensure the machine is correctly aligned with the knee joint to avoid undue strain or discomfort.
• Encourage the client to report any excessive pain, discomfort, or unusual sensations during the use of the CPM machine.
• Monitor the client for potential complications, such as pressure ulcers or skin irritation, caused by prolonged use of the machine.
• Complement CPM therapy with prescribed physical therapy exercises and pain management strategies to optimize recovery.

✘Incorrect answer options:

To prevent the development of contractures. While the CPM machine may help prevent contractures by maintaining joint mobility, its primary purpose is to promote flexion and extension of the artificial joint. Contractures are more commonly associated with prolonged immobility or inactivity, and other interventions, such as regular physical therapy and positioning, are more critical in preventing them.

To reduce pain during initial ambulation. Pain management during ambulation is typically addressed with analgesics, not the CPM machine. Although the machine can improve joint mobility and reduce stiffness, it is not used specifically for pain relief during ambulation.

To decrease lactic acid build-up in leg muscles. Lactic acid build-up is associated with anaerobic muscle activity, such as during intense exercise, and is not directly relevant to post-operative knee replacement recovery. The CPM machine primarily targets joint movement rather than muscular activity.

EXPLANATION

✔Correct answer:

The client’s abdomen feels soft upon palpation.  A soft abdomen upon palpation indicates that the nasogastric (NG) tube suction is functioning correctly by decompressing the stomach and preventing the accumulation of gastric contents, air, or secretions. This is particularly important after abdominal surgery, such as a bowel resection with anastomosis, to reduce the risk of distention, discomfort, and complications like anastomotic leakage or ileus. An NG tube set to intermittent suction helps maintain gastric decompression until bowel function resumes, as indicated by the return of bowel sounds and passage of gas or stool.

A distended or tense abdomen could suggest that the NG tube is not functioning properly, leading to the accumulation of gastric contents or air, which would require prompt investigation (e.g., checking tube patency or repositioning the tube).

Think of the NG tube as a vacuum hose that removes excess air and fluid from the stomach. When the vacuum works, the "balloon" of the stomach deflates, leaving the abdomen soft and comfortable.

Nurse Carla should ensure that the NG tube is functioning properly and assess for any signs of complications.

• Check the NG tube's placement and patency by ensuring that suction is active, gastric contents are being drained, and the tubing is not kinked or blocked.
• Document the amount, color, and consistency of the drainage to monitor for any abnormalities (e.g., bile, blood).
• Assess for signs of abdominal distention or discomfort, as these may indicate improper tube function or bowel obstruction.
• Ensure the suction device is set to the prescribed intermittent setting to prevent gastric mucosal irritation.
• Monitor the client’s electrolyte balance and hydration status, as prolonged NG suction can lead to fluid and electrolyte imbalances.

✘Incorrect answer options:

The client demonstrates the ability to swallow. Swallowing ability is unrelated to NG tube function. While it is an important postoperative assessment (to check for gag reflex and prevent aspiration), it does not confirm that the NG tube is decompressing the stomach effectively.

Active bowel sounds are audible during assessment. The return of bowel sounds indicates the resumption of gastrointestinal motility, which is a positive postoperative sign but is not directly related to NG tube function. Bowel sounds may still be absent or hypoactive in the immediate postoperative period despite a functioning NG tube.

The client’s abdominal dressing remains dry and intact. While a dry and intact dressing is important to monitor for wound healing, it does not reflect whether the NG tube is functioning properly. Dressing assessment is part of incision site care rather than NG tube management.

EXPLANATION

✔Correct answer:

Rice cereal, apple juice, and formula.  At 6 months of age, rice cereal is one of the most appropriate and commonly recommended first foods because it is easily digestible, hypoallergenic, and iron-fortified to address the infant's increasing need for iron. Apple juice (in small amounts) can also be introduced but should be limited to less than 4 ounces per day to avoid excessive sugar intake. Formula (or breast milk) remains the primary source of nutrition for infants at this stage, even as complementary foods are introduced.

The introduction of solid foods at 6 months helps meet the infant's increasing nutritional requirements while developing oral-motor skills. Starting with single-ingredient foods like rice cereal also makes it easier to detect potential food allergies.

Think of rice cereal as a "training food" that prepares Baby Mia’s digestive system to handle more complex foods, much like practicing with easy puzzles before moving to harder ones.

Nurse Clara should educate the parents about safe food introduction and proper feeding practices.

• Start with iron-fortified single-grain cereals like rice or oatmeal, mixed with formula or breast milk for easy swallowing.
• Introduce one new food at a time every 3-5 days to monitor for signs of allergies (e.g., rash, vomiting, diarrhea).
• Avoid adding sugar, salt, or honey to foods, as these are not suitable for infants under 12 months.
• Reinforce that formula or breast milk should remain the infant’s primary source of nutrition until at least 12 months of age.
• Advise against offering foods that pose a choking hazard, such as nuts, raw carrots, or large chunks of food.

✘Incorrect answer options:

Egg white, formula, and orange juice. Egg whites are a common allergen and should be avoided until after 12 months of age. Orange juice is acidic and may cause stomach upset or diaper rash in infants. Formula is appropriate, but this combination is not ideal.

Apple juice, cooked carrots, and whole milk. While cooked carrots are a suitable food for a 6-month-old, whole milk should not be introduced until after 12 months, as it lacks the necessary nutrients (e.g., iron) and can increase the risk of iron-deficiency anemia. Additionally, apple juice should be limited, as excessive consumption can contribute to diarrhea and sugar overload.

Melba toast, egg yolk, and whole milk. Melba toast may pose a choking hazard for a 6-month-old, and whole milk is not recommended until after 12 months. While egg yolks are less allergenic than egg whites, they are usually introduced closer to 8–10 months of age.

EXPLANATION

✔Correct answer:

Episodes of nausea.  Bronchodilators, such as beta-agonists (e.g., albuterol) or methylxanthines (e.g., theophylline), are commonly used to relieve airway obstruction in asthma. These medications relax the smooth muscles of the airways, improving airflow and reducing symptoms like wheezing or shortness of breath. However, they may cause side effects such as nausea, tremors, increased heart rate (tachycardia), headaches, and anxiety due to their systemic effects on beta-adrenergic receptors or stimulation of the central nervous system.

Nausea often occurs as a mild and common side effect, especially with oral or high doses of bronchodilators like theophylline. It results from gastrointestinal irritation or central nervous system stimulation. Monitoring for this symptom allows Nurse Clara to provide appropriate interventions, such as ensuring the medication is taken with food or adjusting the dose under the provider’s guidance.

Think of a bronchodilator as a tool that speeds up the opening of tight airways, but just like revving up an engine too much, it can sometimes cause a "rattling" effect in the body—like nausea or shakiness.

Nurse Clara should educate Mr. Rodriguez about potential side effects and help him manage them effectively.

• Monitor for nausea, tachycardia, restlessness, and tremors, and report persistent or severe symptoms to the healthcare provider.
• Instruct the patient to take oral bronchodilators with food to reduce gastrointestinal upset.
• Teach proper inhaler technique for aerosol bronchodilators to minimize systemic absorption and reduce side effects.
• Advise Mr. Rodriguez to avoid excessive caffeine intake, as it can exacerbate the side effects of bronchodilators, particularly with methylxanthines.
• Reassure the patient that mild nausea and tremors may improve as the body adjusts to the medication.

✘Incorrect answer options:

The development of tinnitus. Tinnitus is not a common side effect of bronchodilators. It is more commonly associated with ototoxic drugs like aminoglycoside antibiotics or high doses of aspirin.

Signs of ataxia. Ataxia (loss of coordination or balance) is not a typical side effect of bronchodilators. It is more commonly associated with neurological conditions or certain medications affecting the central nervous system, such as benzodiazepines or anticonvulsants.

Sudden drops in blood pressure. Bronchodilators do not usually cause hypotension; instead, they may cause a mild increase in blood pressure or heart rate due to their stimulation of the sympathetic nervous system. Sudden drops in blood pressure are more commonly seen with medications like antihypertensives or vasodilators.

EXPLANATION

✔Correct answer:

To prevent a common side effect associated with prednisone.  Cimetidine, a histamine-2 receptor antagonist, is included in Ms. Lawson's treatment plan to prevent gastric irritation or peptic ulcer formation, which is a common side effect associated with prednisone. Prednisone, a corticosteroid, can increase gastric acid secretion, reduce gastric mucosal protective mechanisms, and increase the risk of gastrointestinal (GI) complications such as ulcers and gastritis.

Cimetidine works by reducing gastric acid secretion, thereby protecting the stomach lining from irritation caused by corticosteroids. This is particularly important in clients receiving prolonged or high-dose prednisone therapy, as the combination of immunosuppressive treatments (e.g., methotrexate) can compound the risk of GI complications.

Think of prednisone as a hot drink that could scald your stomach lining. Cimetidine acts like a protective lid, reducing the "heat" of stomach acid to prevent damage.

Nurse Jenna should educate Ms. Lawson about the potential side effects of her medications and strategies to protect her gastrointestinal health.

• Advise Ms. Lawson to take prednisone with food or milk to minimize gastric irritation.
• Educate the client about the purpose of cimetidine and the importance of adhering to the prescribed schedule.
• Monitor for signs of GI distress, such as abdominal pain, nausea, or signs of bleeding (e.g., black tarry stools or hematemesis).
• Encourage avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs), which can further increase the risk of gastric irritation and ulcers.
• Evaluate the client’s GI health regularly to detect any complications early.

✘Incorrect answer options:

To reduce the secretion of pancreatic enzymes. Cimetidine does not affect pancreatic enzyme secretion. This function would be more relevant in conditions like pancreatitis, where medications such as enzyme inhibitors might be used.

To increase the efficacy of methotrexate. While methotrexate is a chemotherapeutic and immunosuppressive agent used in leukemia treatment, cimetidine does not increase its efficacy. Cimetidine's role in this context is specific to gastric protection, not enhancing methotrexate's pharmacological action.

To stimulate gastrointestinal peristalsis. Cimetidine does not stimulate GI peristalsis. Medications like metoclopramide or prokinetic agents are used for this purpose in cases of gastroparesis or GI motility disorders.

EXPLANATION

✔Correct answer:

Cultivating a sense of industry.  According to Erik Erikson's psychosocial theory of development, the primary developmental task for children in middle childhood (ages 6-12) is to develop a sense of industry vs. inferiority. This stage focuses on the child's ability to achieve competence in skills and tasks valued by society, such as academics, sports, and social interactions. Success in this stage leads to a sense of pride and accomplishment (industry), while failure or consistent criticism can result in feelings of inadequacy or inferiority.

At this stage, children like Jacob are highly motivated to learn and master new skills. They are often eager to complete tasks, gain approval from peers and adults, and contribute to their environment. Encouraging and recognizing their efforts helps build confidence and self-esteem, preparing them for future challenges.

Imagine this stage like planting seeds in a garden. As Jacob works hard to tend to his "garden" (learning new skills and accomplishing tasks), the praise and encouragement he receives are like sunshine and water that help the seeds grow strong (confidence and competence).

Nurse Ava can help Jacob’s parents support his development by emphasizing the importance of positive reinforcement, structured opportunities for learning, and fostering a healthy sense of achievement.

• Encourage parents to recognize and celebrate Jacob’s achievements, no matter how small, to promote a sense of competence.
• Suggest enrolling Jacob in extracurricular activities like sports, music, or clubs to enhance skill-building and socialization.
• Advise against harsh criticism or unrealistic expectations, which can damage Jacob’s confidence and lead to feelings of inferiority.
• Teach parents to provide a structured routine at home, where Jacob can participate in tasks like homework or chores, further promoting responsibility and a sense of accomplishment.
• Monitor Jacob’s emotional well-being for signs of low self-esteem or frustration, which might indicate challenges with achieving a sense of industry.

✘Incorrect answer options:

Building trust in others. Developing trust occurs during the infancy stage (birth to 18 months) under the psychosocial task of trust vs. mistrust. During this stage, infants learn to trust caregivers who consistently meet their needs. This is not the primary task for children in middle childhood.

Developing a sense of initiative. Developing initiative is the psychosocial task of the early childhood stage (3-6 years) under the framework of initiative vs. guilt. At this stage, children begin to assert themselves through play, exploration, and decision-making.

Gaining independence. Gaining independence is associated with the toddler stage (18 months to 3 years) under the task of autonomy vs. shame and doubt. This involves learning to do things for oneself, such as walking, eating, and toileting, and is not the central focus for middle childhood.

EXPLANATION

✔Correct answer:

Possible epiglottitis.  The symptoms described—drooling, a muffled voice, and a fever—are classic warning signs of epiglottitis, a potentially life-threatening condition. Epiglottitis is an inflammation and swelling of the epiglottis (a small cartilage flap that covers the trachea during swallowing), most commonly caused by bacterial infection such as Haemophilus influenzae type B (HiB). Swelling of the epiglottis can rapidly obstruct the airway, making this a medical emergency.

Key Indicators:

1. Drooling occurs because the child cannot swallow saliva due to throat swelling.
2. Muffled voice (or "hot potato voice") results from the inflamed structures in the throat.
3. High fever reflects the systemic response to the infection.
4. Other possible signs include tripod positioning (leaning forward with arms supporting the body to ease breathing) and inspiratory stridor (a harsh sound when breathing in).

This condition requires immediate intervention to secure the airway and administer appropriate treatment such as antibiotics and corticosteroids. Delayed treatment can lead to complete airway obstruction and respiratory arrest.

Imagine the airway as a straw through which you breathe. If the epiglottis swells, it acts like a lid that is closing the straw, making it harder to breathe. Without quick action to lift the lid (reduce the swelling), the airway could completely close.

Nurse Kelly must act promptly to prioritize airway management while preparing for medical interventions.

• Do not attempt a throat examination (e.g., using a tongue depressor) as this could trigger complete airway obstruction.
• Keep the child calm to avoid worsening airway swelling (crying or agitation increases oxygen demand).
• Provide humidified oxygen as tolerated to ease breathing.
• Alert the physician immediately and prepare for possible intubation or tracheostomy if airway obstruction worsens.
• Administer prescribed antibiotics and corticosteroids to reduce the infection and inflammation.

✘Incorrect answer options:

A case of strep throat. Strep throat caused by Streptococcus pyogenes can cause a sore throat, fever, and difficulty swallowing, but it typically does not present with drooling or a muffled voice. These symptoms are more indicative of airway obstruction, not just throat infection.

Laryngotracheobronchitis (croup). Croup is a viral infection causing inflammation of the upper airway, often presenting with a "barking" cough, inspiratory stridor, and mild fever. Drooling and a muffled voice are not characteristic of croup, which typically has a gradual onset compared to the acute presentation of epiglottitis.

Early-stage bronchiolitis. Bronchiolitis is a lower respiratory tract infection, usually caused by respiratory syncytial virus (RSV), leading to wheezing, nasal congestion, and fever in infants and young children. It does not cause drooling, muffled voice, or airway obstruction related to the epiglottis.

EXPLANATION

✔Correct answer:

Cyanotic discoloration of the hands and feet.  A 5-minute Apgar score of 9 indicates that Baby Liam is in excellent condition, but a slightly reduced score is likely due to acrocyanosis, a common finding in newborns. Acrocyanosis refers to the bluish discoloration of the hands and feet caused by immature peripheral circulation, which is normal and typically resolves as the newborn's circulatory system adjusts after birth. This mild cyanosis does not affect the central body (trunk or face) and is not a sign of respiratory or cardiac distress.

The Apgar score evaluates five criteria: Appearance (skin color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration, each rated from 0 to 2. A score of 1 under the "Appearance" category is given for acrocyanosis, as the skin is pink centrally but blue at the extremities. This is a normal finding in many healthy newborns, particularly those delivered via C-section, as their transition from intrauterine to extrauterine circulation may take slightly longer.

Think of acrocyanosis like a garden hose with water starting to flow after winter. The water (blood) first reaches the main branches (central circulation) before it fully reaches the smaller branches (extremities like hands and feet).

Nurse Megan should reassure the parents that this is a normal finding and monitor Baby Liam's transition to extrauterine life to ensure no other complications arise.

• Monitor Baby Liam for resolution of acrocyanosis as his peripheral circulation improves, which usually occurs within the first 24–48 hours after birth.
• Keep the newborn warm and maintain a neutral thermal environment, as cold stress can exacerbate acrocyanosis.
• Educate the parents about acrocyanosis, explaining that it is normal and not indicative of an oxygenation problem in otherwise healthy newborns.
• Assess for other potential causes of cyanosis, such as central cyanosis or respiratory distress, if additional symptoms (e.g., grunting, nasal flaring, or persistent blue lips) are present.
• Document the Apgar score and any changes in the newborn's appearance and circulation.

✘Incorrect answer options:

Mottled appearance noted on the trunk. Mottling, a lacy red or bluish pattern on the skin, may occur due to immature circulation, but it is not typically scored in the Apgar assessment unless it indicates more severe issues like poor perfusion. Mottling is less common than acrocyanosis and unlikely to explain a score of 9.

Presence of conjunctival hemorrhages. Conjunctival hemorrhages are small blood vessel ruptures in the eyes that can occur due to the pressure of delivery. While these are common, they do not affect the Apgar score, as they are not part of the criteria assessed.

A respiratory rate between 20–28 breaths per minute. A normal newborn respiratory rate ranges from 30–60 breaths per minute. A respiratory rate below 30 would indicate a problem and significantly lower the Apgar score. However, this finding is inconsistent with a score of 9, as the respiratory category would have received a score of 0 or 1, not 2.

EXPLANATION

✔Correct answer:

Provide sterile water to the newborn between formula feedings.  Physiologic jaundice is a common condition in newborns caused by an immature liver's inability to process and excrete bilirubin effectively. Phototherapy is a primary treatment for jaundice, as it helps break down bilirubin in the skin into a water-soluble form that can be excreted in urine and stool.

During phototherapy, newborns are at an increased risk for dehydration due to the loss of fluids caused by the heat from phototherapy lights and increased bilirubin excretion. Providing sterile water or supplemental feedings between formula or breastfeeding sessions helps maintain adequate hydration and supports bilirubin excretion.

Think of bilirubin as trash, and phototherapy as sunlight that breaks it into smaller pieces that can be washed away. Fluids (like water) act like a flowing river that carries the trash out of the body. Without enough water, the trash builds up and can’t be removed efficiently.

Nurse Riley must implement strategies to ensure that phototherapy is safe and effective while addressing hydration and skin protection needs.

• Monitor the newborn’s hydration status by assessing for signs of dehydration, such as sunken fontanelles, reduced wet diapers, or dry mucous membranes.
• Encourage frequent feeding (breast or formula) to promote hydration and bilirubin excretion through stools and urine.
• Provide sterile water supplementation between feeds if ordered by the healthcare provider.
• Regularly reposition the newborn under the phototherapy lights to ensure even exposure and reduce the risk of skin breakdown.
• Protect the baby’s eyes with an eye shield to prevent damage from phototherapy light exposure, and check frequently for proper placement.
• Monitor the baby’s bilirubin levels and stool output, as greenish stools indicate the excretion of bilirubin.

✘Incorrect answer options:

Use an emollient to keep the baby’s skin hydrated and prevent dryness. Emollients are generally not recommended during phototherapy, as they can interfere with the absorption of light into the skin, reducing the efficacy of the treatment. Proper hydration through feeding or sterile water is the best way to address potential dryness.

Wear a gown, gloves, and mask while attending to the infant. While infection control is always important, standard precautions (hand hygiene and gloves when necessary) are sufficient for phototherapy. There is no indication that full PPE (personal protective equipment) is required unless there is a known risk of infection.

Avoid placing the newborn under enteric isolation precautions. Isolation precautions are not relevant to the treatment of physiologic jaundice. Phototherapy is used to treat jaundice, not an infectious condition, so enteric precautions are unnecessary.

EXPLANATION

✔Correct answer:

3 p.m.  NPH insulin (Neutral Protamine Hagedorn) is an intermediate-acting insulin with an onset of action of 1–2 hours, a peak action of 4–12 hours, and a duration of action of 12–18 hours. Since Mrs. Carter received her NPH insulin at 7 a.m., the peak time—when the risk of hypoglycemia is highest—would be between 11 a.m. and 7 p.m., with the most likely occurrence near the middle of this range, approximately 3 p.m..

Hypoglycemia is most likely to occur during the insulin's peak action because this is when it is most effective at lowering blood glucose levels. Nurse Rachel should monitor Mrs. Carter for symptoms of hypoglycemia during this time, such as shakiness, sweating, confusion, or hunger, and ensure that she consumes an appropriate snack or meal to stabilize her blood sugar.

Think of NPH insulin like a rollercoaster ride that climbs slowly (onset), reaches its highest peak between 4–12 hours, and then slowly comes down. The peak is when it is working hardest and when blood sugar levels are most likely to drop.

Nurse Rachel should take proactive steps to manage Mrs. Carter's risk of hypoglycemia during this peak period.

• Ensure Mrs. Carter consumes a mid-morning snack or a carbohydrate-rich lunch to maintain stable glucose levels during the insulin's peak action.
• Educate Mrs. Carter to recognize and report symptoms of hypoglycemia, such as sweating, trembling, confusion, or irritability.
• Monitor blood glucose levels before meals, at mid-afternoon, and as needed to identify and treat hypoglycemia promptly.
• Encourage Mrs. Carter to carry a fast-acting source of glucose, such as glucose tablets or juice, in case symptoms of hypoglycemia occur.
• Document and report any episodes of hypoglycemia to adjust the insulin regimen if needed.

✘Incorrect answer options:

8 a.m. This time is too soon for hypoglycemia to occur, as NPH insulin takes 1–2 hours to begin acting. By 8 a.m., it would not yet have reached its peak effect.

10 a.m. While this time falls within the earlier part of the insulin's peak window (11 a.m.–7 p.m.), it is less likely to be the point of greatest hypoglycemic risk. The risk increases closer to the midpoint of the peak period.

5 a.m. By this time, the insulin administered at 7 a.m. the previous day would have already worn off, as NPH insulin has a maximum duration of 12–18 hours. Hypoglycemia at this time would more likely be caused by basal insulin or other factors, not the morning NPH dose.

EXPLANATION

✔Correct answer:

Risk for Injury related to impaired vision and altered depth perception.  The priority nursing diagnosis for Mr. Lee, a client with a detached retina, is Risk for Injury. A detached retina significantly impairs vision, alters depth perception, and increases the client's risk for falls and other accidents. Ensuring the client’s safety is critical because impaired vision can make it difficult for the client to navigate their environment safely. This risk is further heightened by potential activity restrictions after surgery, which may leave the client disoriented or unsteady.

Detached retina often leads to a partial or complete loss of vision in the affected eye, and immediate surgical intervention is required to repair the retina. Postoperatively, clients may need to maintain specific positions (e.g., face-down) to ensure proper healing, which can further affect their mobility and safety. Prioritizing injury prevention addresses the most immediate threat to the client’s well-being.

Think of impaired vision like walking through a room blindfolded. Without adequate precautions, the risk of tripping or bumping into something increases significantly, making safety the top priority.

The nursing team should implement measures to minimize Mr. Lee's risk for injury while promoting recovery and comfort.

• Ensure the client’s environment is free of hazards, such as loose rugs, clutter, or uneven surfaces, to prevent falls.
• Provide adequate lighting in the room and ensure the call bell is within easy reach at all times.
• Encourage the client to move slowly and request assistance when ambulating or performing activities of daily living (ADLs).
• Educate the client and family about any postoperative positioning requirements (e.g., face-down positioning) to promote retinal healing.
• Monitor for complications, such as signs of retinal re-detachment or increased intraocular pressure, which may worsen vision or safety risks.

✘Incorrect answer options:

Risk for Infection related to postoperative recovery. While infection prevention is important following retinal surgery, infection is not the most immediate concern for a detached retina. Postoperative infections are relatively rare if proper surgical care and hygiene are maintained.

Impaired Sensory Perception related to vision changes. Impaired sensory perception is accurate and relevant because a detached retina results in vision loss, which can affect the client’s ability to perceive their environment. However, this diagnosis is not the most critical since addressing the risk for injury will inherently address the sensory deficit.

Anxiety related to potential loss of vision. Anxiety is a valid psychosocial concern for clients with retinal detachment, as vision loss can be distressing. However, physiological safety, such as injury prevention, takes precedence over psychosocial needs in the hierarchy of care priorities.

EXPLANATION

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Provide small, frequent meals throughout the day.  In clients with AIDS-related wasting syndrome, poor nutrient absorption and low caloric intake contribute to severe weight loss and muscle wasting. Offering small, frequent meals throughout the day can enhance nutrient intake by making eating more manageable and less overwhelming for clients who may experience early satiety, fatigue, nausea, or gastrointestinal discomfort. These smaller meals are easier to digest and absorb, optimizing the client’s overall caloric and nutritional intake.

By spreading meals throughout the day, Nurse Sofia ensures Mr. Alvarez receives adequate calories and essential nutrients to help combat wasting syndrome, maintain lean body mass, and improve energy levels. This approach also minimizes the risk of overwhelming the gastrointestinal system, which is often compromised in clients with AIDS due to chronic inflammation, infections, or malabsorption.

Think of the digestive system as a small funnel. Pouring too much food (or nutrients) at once can cause overflow (discomfort or malabsorption). Offering smaller portions throughout the day helps ensure everything "flows through" smoothly and efficiently.

Nurse Sofia should implement other strategies alongside small, frequent meals to further address Mr. Alvarez's nutritional challenges and improve his overall health.

• Incorporate high-calorie, nutrient-dense foods (e.g., peanut butter, eggs, avocados) to maximize calorie intake without increasing meal volume.
• Ensure adequate protein intake to promote muscle maintenance and healing.
• Offer foods that are easy to digest and less likely to irritate the gastrointestinal tract.
• Consider the use of nutritional supplements, such as high-calorie shakes, to increase intake when appetite is limited.
• Monitor the client for signs of malabsorption, such as diarrhea or steatorrhea, and consult with a dietitian if needed for tailored recommendations.

✘Incorrect answer options:

Ensure all foods are thoroughly cooked. While thoroughly cooking food is essential for clients with AIDS to reduce the risk of infections (e.g., from bacteria like Salmonella or Listeria), this does not directly address Mr. Alvarez’s malabsorption or nutritional intake. It is an important safety measure but not a primary strategy for managing wasting syndrome.

Offer yogurt and buttermilk as snacks between meals. Although yogurt and buttermilk are nutrient-rich and may provide probiotics, they might exacerbate gastrointestinal discomfort in clients with lactose intolerance, which is common in individuals with AIDS. Any dairy product recommendations should be personalized based on the client’s tolerance.

Encourage increased fluid intake. While adequate hydration is important, increasing fluid intake does not directly address malabsorption or caloric needs. Excess fluids might also contribute to early satiety, reducing overall food intake.

EXPLANATION

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Shakiness or tremulousness.  Shakiness or tremulousness is a hallmark symptom of hypoglycemia, which occurs when blood glucose levels drop below the normal range (usually <70 mg/dL). This symptom results from the activation of the sympathetic nervous system in response to low glucose levels. When glucose levels fall, the body releases hormones like epinephrine (adrenaline) to trigger glycogen breakdown and increase blood sugar. This adrenergic response can lead to shakiness, sweating, tachycardia, and a sense of nervousness or anxiety.

If not addressed promptly, hypoglycemia can progress to more severe symptoms, including confusion, irritability, slurred speech, and even seizures or loss of consciousness. Educating Mr. Carter to recognize early symptoms, like shakiness, ensures he can take action (e.g., consuming a quick source of glucose) to prevent complications.

Imagine your body as a car that needs fuel (glucose) to run. Hypoglycemia is like running low on gas—your body starts to "shake" and signal distress before it completely stops functioning.

Nurse Ella should emphasize the importance of recognizing hypoglycemia's symptoms and responding appropriately.

• Teach Mr. Carter the early symptoms of hypoglycemia, such as shakiness, sweating, dizziness, hunger, and palpitations.
• Advise carrying a quick-acting carbohydrate (e.g., glucose tablets, juice, or hard candy) at all times to treat hypoglycemia promptly.
• Encourage regular blood glucose monitoring, especially before meals, after insulin administration, and during activities that may increase glucose utilization (e.g., exercise).
• Educate on the 15-15 rule: consume 15 grams of fast-acting carbohydrate, wait 15 minutes, and recheck blood sugar. Repeat as necessary until levels normalize.
• Instruct on the use of glucagon injection for severe hypoglycemia when the client is unable to eat or drink.

✘Incorrect answer options:

A slow and steady pulse. Hypoglycemia typically causes tachycardia (rapid pulse), not a slow and steady pulse, due to the adrenergic response. A slow pulse may occur in other conditions, such as hypothyroidism or certain cardiac disorders, but not hypoglycemia.

Persistent feelings of nausea. Nausea is more commonly associated with hyperglycemia, diabetic ketoacidosis, or gastrointestinal conditions. While it can occur in severe hypoglycemia, it is not one of the early or hallmark symptoms.

Skin that appears flushed or reddened. Hypoglycemia often causes cool, clammy, and pale skin, not flushed or reddened skin. Flushed skin may be more typical of hyperglycemia or febrile conditions.

EXPLANATION

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The vastus lateralis muscle.  The vastus lateralis muscle, located on the anterolateral aspect of the thigh, is the preferred and safest site for intramuscular (IM) injections in newborns and infants. This muscle is well-developed at birth, providing an adequate and safe location for IM administration of medications like vitamin K. It is free of major blood vessels and nerves, reducing the risk of injury.

Vitamin K is routinely administered to newborns shortly after birth to prevent hemorrhagic disease of the newborn, as newborns have low levels of vitamin K and an immature clotting system. Administering the injection into the vastus lateralis ensures optimal absorption and reduces the risk of complications.

Think of the vastus lateralis as a strong, reliable storage pocket in the leg where medications can be safely delivered without risk of hitting delicate structures like nerves or large blood vessels.

Nurse Kelly should follow the proper technique to ensure a safe and effective injection.

• Locate the vastus lateralis by dividing the thigh into thirds horizontally and vertically, selecting the middle third on the outer (lateral) aspect of the thigh.
• Use a 25–27 gauge, 5/8-inch needle for the injection, and inject at a 90-degree angle.
• Administer a single 0.5 mg or 1 mg dose of vitamin K intramuscularly, as prescribed, typically within the first hour after birth.
• Provide comfort measures for the newborn, such as swaddling or skin-to-skin contact, after the injection.
• Educate parents about the importance of the vitamin K injection in preventing serious bleeding disorders in their baby.

✘Incorrect answer options:

The rectus femoris muscle. Although the rectus femoris muscle is located near the vastus lateralis, it is not the preferred site for newborn injections because it is closer to major blood vessels and nerves, increasing the risk of injury.

The deltoid muscle. The deltoid muscle is not used for injections in newborns due to its small size and insufficient development, which can lead to poor absorption and increased risk of injury to nearby structures.

The dorsogluteal muscle. The dorsogluteal muscle is not recommended for newborns or infants because it is not well-developed at this age, and there is a risk of damaging the sciatic nerve or hitting major blood vessels in this area.

EXPLANATION

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Their actions are guided by the consequences they face.  According to Kohlberg's stages of moral development, preschool-aged children (approximately 3–6 years old) are in the Preconventional Level, specifically Stage 1: Obedience and Punishment Orientation. At this stage, their moral reasoning is driven by the desire to avoid punishment or gain rewards, rather than an internalized sense of right and wrong. Their actions are guided by external consequences, and they see rules as fixed and absolute.

For example, a preschooler might refrain from taking a toy that doesn’t belong to them because they fear being scolded (negative consequence), not because they understand the concept of fairness or empathy.

Think of this stage like a game where preschoolers follow the "rules" because they want to avoid losing points (punishment) or gain points (rewards), rather than understanding the reasons behind the rules.

When teaching parents about moral development, Nurse Carla should emphasize strategies that support positive behavior while reinforcing understanding of consequences.

• Encourage parents to use positive reinforcement to guide behavior, such as praising good actions and explaining the reasons behind rules.
• Help parents understand that preschool-aged children may not yet grasp complex moral principles but respond well to simple explanations linked to consequences.
• Teach parents to be consistent with discipline, as predictability helps children learn which behaviors lead to specific consequences.
• Advise parents to avoid harsh punishments and instead focus on teaching empathy and fairness through modeling and practice.
• Highlight the importance of fostering a nurturing environment that allows the child to feel secure as they explore the concepts of right and wrong.

✘Incorrect answer options:

They believe obeying adults is the right thing to do. This reasoning aligns more closely with Stage 2: Individualism and Exchange or Stage 3: Good Interpersonal Relationships, which emerge later in childhood. Preschoolers are not yet focused on obeying adults because it’s the "right thing to do"; their behavior is still centered on avoiding punishment or gaining rewards.

Respecting parental authority is highly valued. Respect for authority becomes prominent during the Conventional Level, typically seen in school-aged children (7–12 years old), when children begin to internalize social norms and rules set by parents and authority figures.

Pleasing others is perceived as good behavior. Pleasing others as a motivation for behavior is associated with Stage 3: Good Interpersonal Relationships, which occurs later during the school-age years. Preschoolers are more egocentric and focus on personal consequences rather than social approval.

EXPLANATION

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Tenseness or bulging of the anterior fontanel.  In infants, tenseness or bulging of the anterior fontanel is a critical sign of increased intracranial pressure (ICP). The fontanels (soft spots on the skull) allow for expansion of the skull as the brain grows, and they also provide a visible indicator of abnormal pressure within the skull. In cases of bacterial meningitis, inflammation, swelling, and increased cerebrospinal fluid (CSF) can elevate ICP, leading to bulging of the fontanel. This finding is especially important in infants, who cannot verbally express symptoms such as headache or vision changes.

Additional signs of increased ICP in infants may include:

• Irritability and inconsolable crying
• Poor feeding
• Vomiting
• Increased head circumference
• Altered level of consciousness (lethargy or drowsiness)
• Seizures

Monitoring for these signs is vital to prevent complications such as brain herniation, a life-threatening condition that can result from sustained high ICP.

Think of the fontanel like a balloon—when the pressure inside increases (from fluid or swelling), the surface (the fontanel) becomes more tense and bulges outward.

Nurse Sofia should implement measures to monitor and manage ICP effectively while addressing the underlying bacterial infection.

• Monitor the anterior fontanel regularly for bulging or tenseness and assess Noah’s head circumference to track changes in ICP.
• Observe for additional signs of ICP, such as changes in vital signs (Cushing’s triad: increased blood pressure, decreased heart rate, and irregular respirations).
• Maintain the infant’s head in a neutral position to promote venous drainage and reduce ICP.
• Minimize stimuli (e.g., noise, bright lights) that could exacerbate irritability and increase ICP.
• Administer prescribed antibiotics and corticosteroids to treat the infection and reduce inflammation.
• Collaborate with the healthcare team to prepare for potential interventions, such as a ventriculostomy or other procedures to manage severe ICP elevation.

✘Incorrect answer options:

Swelling around the infant’s eyes (periorbital edema). While periorbital edema may occur in some systemic infections, it is not a direct sign of increased ICP. In bacterial meningitis, swelling of the meninges and brain tissue, not the eyes, is the primary concern for ICP monitoring.

Presence of a positive Babinski reflex. A positive Babinski reflex (toes fan outward when the sole is stroked) is normal in infants up to 12 months of age. It is not an indicator of increased ICP in this age group and is unrelated to meningitis or its complications.

Lack of flexibility in the infant’s arm crossing midline (negative scarf sign). The scarf sign is typically used to assess muscle tone in newborns, with a negative scarf sign indicating normal tone. It is not associated with increased ICP or bacterial meningitis, making it an irrelevant assessment in this context.

EXPLANATION

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Encourage the client to increase fluid intake.  Cyclophosphamide (Cytoxan) is a cytotoxic immunosuppressive agent used to treat nephrotic syndrome by reducing immune-mediated kidney damage and proteinuria. However, cyclophosphamide can cause significant side effects, particularly hemorrhagic cystitis, which is characterized by irritation and bleeding in the bladder. Increasing fluid intake (at least 2–3 liters per day) helps dilute the urine, flush out toxic metabolites, and reduce the risk of bladder irritation.

Adequate hydration is the most effective way to prevent cyclophosphamide-induced bladder complications. Nurse Lily should emphasize the importance of drinking water regularly throughout the day and urinating frequently to prevent metabolite buildup in the bladder.

Think of the bladder as a sink where cyclophosphamide leaves residue. Increasing fluid intake is like running water to wash the residue away, keeping the sink clean and preventing clogs or damage.

Nurse Lily should also monitor for other potential side effects of cyclophosphamide and provide appropriate education.

• Encourage at least 2–3 liters of fluid daily, unless contraindicated by other conditions like heart failure or fluid overload.
• Advise the client to empty the bladder frequently (every 2–3 hours) to prevent prolonged contact of the drug metabolites with the bladder lining.
• Educate the client to report any symptoms of hemorrhagic cystitis, such as blood in the urine, pain during urination, or increased urinary urgency/frequency.
• Monitor for other side effects, such as bone marrow suppression, which increases the risk of infection, and gastrointestinal disturbances like nausea.
• Advocate for co-administration of mesna (a uroprotective agent), if prescribed, to further reduce the risk of bladder toxicity.

✘Incorrect answer options:

Arrange for a low-protein diet plan. While dietary changes, such as a low-protein diet, may be considered for clients with nephrotic syndrome to reduce kidney workload, this intervention does not specifically address cyclophosphamide’s side effects. A balanced protein intake is often recommended instead, based on the client's renal function and proteinuria levels.

Use only mild soap and water for bathing. Skin care is not directly related to cyclophosphamide administration. This intervention is more relevant to clients with skin sensitivity or conditions such as eczema, not nephrotic syndrome or cyclophosphamide side effects.

Offer extra warmth for inflamed, swollen joints. Swollen joints are not a typical side effect of cyclophosphamide or nephrotic syndrome. This intervention is more appropriate for clients with inflammatory joint conditions like arthritis.

EXPLANATION

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Diplopia.  Diplopia (double vision) is a common symptom associated with multiple sclerosis (MS) and may indicate an exacerbation or flare-up of the disease. MS is a chronic autoimmune disorder characterized by demyelination of the central nervous system, which disrupts nerve signal transmission. Visual disturbances, including diplopia, blurred vision, or optic neuritis, often occur during MS flare-ups because the disease commonly affects the cranial nerves and areas of the brain responsible for vision.

During an exacerbation, inflammatory activity increases in the CNS, leading to temporary worsening of symptoms such as muscle weakness, sensory disturbances, fatigue, or visual problems like diplopia. These symptoms may improve over time with treatment (e.g., corticosteroids) or spontaneously during remission periods.

Think of the nervous system as a set of insulated wires sending clear signals to different parts of the body. In MS, the insulation (myelin sheath) is damaged, causing the signals to "short-circuit," leading to symptoms like blurred or double vision.

Nurse Laura should educate Ms. Harper about managing exacerbations and monitoring symptoms.

• Monitor for other common signs of MS exacerbations, such as muscle weakness, numbness or tingling, impaired coordination, and fatigue.
• Encourage Ms. Harper to report worsening symptoms promptly, as early intervention can minimize flare-up severity.
• Administer prescribed medications, such as corticosteroids, to reduce inflammation and manage exacerbations.
• Encourage strategies to avoid triggers of exacerbations, such as stress, infections, and overheating.
• Provide emotional support and resources for managing the chronic nature of MS, including referrals to support groups or specialists.

✘Incorrect answer options:

Anorexia. Anorexia (loss of appetite) is not a primary symptom of MS or a typical sign of an exacerbation. While some MS clients may experience changes in appetite due to fatigue, depression, or medication side effects, anorexia is not directly caused by the disease process.

Seizures. While seizures can occasionally occur in MS clients, they are relatively rare and not a hallmark symptom of MS exacerbations. Seizures are more commonly associated with conditions involving cortical damage, such as epilepsy or traumatic brain injury.

Insomnia. Insomnia may be a secondary issue for MS clients, often related to fatigue, pain, or emotional distress caused by the disease. However, it is not a symptom of an MS flare-up or a direct result of CNS demyelination.

EXPLANATION

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A history of gout.  A history of gout is strongly linked to the development of renal calculi (kidney stones), specifically uric acid stones. Gout is a condition characterized by elevated levels of uric acid in the blood (hyperuricemia), which can lead to the precipitation of uric acid crystals in the kidneys, forming stones. These stones are more likely to develop in acidic urine, a common finding in individuals with gout. Additionally, dehydration or poor fluid intake, often seen in clients with gout, can further concentrate the urine and promote stone formation.

Gout and uric acid kidney stones both stem from issues with uric acid metabolism, making this condition a primary contributing factor to stone development. Nurse Hannah should assess Mr. Thompson's history of gout or hyperuricemia and advise interventions to reduce uric acid levels, such as dietary changes, increased hydration, and medications like allopurinol.

Think of the kidneys as a water filter. In gout, there’s too much uric acid, like too much debris in the water. The excess debris clumps together, forming "stones" that clog the filter.

Nurse Hannah should provide education and care aimed at preventing further stone formation and managing gout-related risks.

• Encourage increased fluid intake (2-3 liters per day) to dilute the urine and reduce the risk of stone formation.
• Advise dietary modifications, such as reducing purine-rich foods (e.g., red meat, shellfish, alcohol), which can raise uric acid levels.
• Monitor for signs of complications, such as infection or obstruction, which may require urgent intervention.
• Administer prescribed medications, such as allopurinol, to lower uric acid levels, or potassium citrate to alkalinize the urine.
• Promote early recognition of gout flare-ups to prevent worsening of hyperuricemia.

✘Incorrect answer options:

A previous episode of pancreatitis. Pancreatitis is not directly linked to kidney stone formation. It is more commonly associated with gallstones or alcohol use. Although pancreatitis can cause dehydration, which may indirectly contribute to stone formation, it is not a primary cause.

A recent fractured femur. While prolonged immobilization following a fracture can lead to calcium release from bones, increasing the risk of calcium stones, this is less likely to be the main factor unless there was extended immobility. Gout is a more direct and common contributor to kidney stone development.

Chronic disc disease. Chronic disc disease is not a known risk factor for renal calculi. Although this condition can cause pain and immobility, it does not affect the metabolic processes (e.g., calcium or uric acid metabolism) directly associated with stone formation.

EXPLANATION

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Assign a staff member to stay with the client for an hour after meals.  For clients with anorexia nervosa, post-meal monitoring is essential to ensure they do not engage in compensatory behaviors such as self-induced vomiting, excessive exercise, or hiding food. Assigning a staff member to remain with the client for one hour after meals helps prevent these behaviors and reinforces accountability. This strategy is part of a structured and supportive approach to fostering healthier eating habits and preventing relapses in disordered eating behaviors.

Anorexia nervosa is a serious mental health condition characterized by a distorted body image and an intense fear of gaining weight. Treatment requires careful monitoring of food intake, weight, and the psychological factors contributing to the disorder. Post-meal observation ensures that the therapeutic goals of nutritional rehabilitation and behavioral modification are met.

Think of this intervention like placing a lifeguard near a swimming pool. The lifeguard doesn't just ensure people enter the pool safely but also watches to prevent unsafe behaviors afterward. Similarly, staying with the client ensures they don't undo the progress made during meals.

Nurse Jenna should design a care plan that includes physical, emotional, and nutritional support tailored to Megan's needs. The post-meal monitoring is part of a broader effort to provide structure and consistency in her recovery.

• Assign a staff member to stay with Megan during and for one hour after meals to observe her behavior and provide support as needed.
• Encourage Megan to express her feelings about eating and body image to address underlying psychological concerns.
• Collaborate with a dietitian to create a balanced meal plan that meets Megan's nutritional needs while gradually increasing caloric intake.
• Reinforce positive behaviors with therapeutic techniques, such as cognitive-behavioral therapy (CBT), to challenge distorted thoughts about food and body image.
• Involve Megan in setting realistic and achievable treatment goals to foster a sense of control and motivation for recovery.

✘Incorrect answer options:

Weigh the client immediately following meals. Weighing a client after meals may exacerbate their anxiety and reinforce an unhealthy preoccupation with weight. Regular weights should be taken at the same time each day (typically in the morning before meals) and in a nonjudgmental, supportive manner to assess progress without creating additional stress.

Arrange high-protein foods prominently on the client’s plate. While protein is important, focusing prominently on certain foods may overwhelm or trigger Megan, as clients with anorexia often have food aversions or rigid eating rules. A balanced, gradual introduction of all food groups is more appropriate.

Offer the client smaller, child-size utensils for eating. Providing smaller utensils is not a therapeutic intervention and may inadvertently infantilize Megan or support restrictive eating behaviors. Standard utensils should be used to normalize eating habits and promote recovery.

EXPLANATION

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The return of the client’s gag reflex.  After an esophagoscopy, the gag reflex is a crucial safety consideration before allowing the client to consume fluids or food. During the procedure, a local anesthetic is often used to numb the throat, which suppresses the gag reflex. If fluids or food are given before the gag reflex returns, the patient is at risk of aspiration, which can lead to pneumonia or airway obstruction.

The gag reflex is a protective mechanism involving cranial nerves IX (glossopharyngeal) and X (vagus), which prevent foreign material from entering the airway. The return of this reflex indicates that the throat's sensation and swallowing ability have normalized, ensuring safe intake of fluids or food.

Think of the gag reflex like a door with an automatic lock (the airway's protective mechanism). If the lock is deactivated (reflex suppressed), anything entering could harm the inside of the house (lungs). Checking that the lock works again ensures the door is secure before allowing entry (fluids).

Nurse Dana should take a proactive approach to ensure Mr. Carter's safety by monitoring for signs of gag reflex return and addressing his hydration and nutritional needs appropriately.

• Assess the client for the return of the gag reflex by gently stimulating the back of the throat with a tongue depressor or observing for a natural swallowing response.
• Educate the client about the importance of waiting until the reflex returns before eating or drinking.
• Provide alternative hydration methods, such as IV fluids, until the gag reflex has returned.
• Monitor for signs of aspiration, such as coughing, choking, or changes in respiratory status.
• Document the return of the gag reflex and notify the healthcare provider if it is delayed.

✘Incorrect answer options:

The client’s level of consciousness. While assessing the level of consciousness is important post-procedure to evaluate for sedation effects, it is not the priority in this case when deciding if fluids can be offered. The gag reflex is more directly related to aspiration risk.

The client’s urinary output. Monitoring urinary output is an essential part of overall postoperative care, especially for assessing hydration status or renal function. However, it does not address the immediate risk associated with offering fluids after an esophagoscopy.

The ability to move their extremities. Assessing extremity movement is relevant in conditions such as spinal or neurological injuries but does not apply to the priority concern in esophagoscopy recovery, which focuses on swallowing safety.

EXPLANATION

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Use an eye shield while sleeping at night.  After cataract surgery, protecting the eye during recovery is crucial to prevent accidental injury or contamination, especially while sleeping. An eye shield helps to safeguard the surgical site from rubbing, pressure, or exposure to contaminants, which could increase the risk of infection, irritation, or complications like dislodging the intraocular lens implant.

Post-operative care for cataract surgery focuses on minimizing infection risk, promoting healing, and ensuring proper alignment of the intraocular lens. Using an eye shield during sleep provides a physical barrier that prevents inadvertent damage while the patient is less aware of their actions.

Imagine your newly operated eye as a freshly planted seedling. The eye shield acts like a small fence around the seedling to protect it from being stepped on or damaged while it grows stronger.

Nurse Simone should educate Mrs. Ellis about proper usage and other protective measures to ensure a smooth recovery.

• Instruct the patient to wear the eye shield at night for at least one week or as recommended by the surgeon.
• Emphasize the importance of avoiding activities that could increase intraocular pressure, such as heavy lifting, bending, or straining.
• Encourage adherence to prescribed eye drop regimens (e.g., antibiotic and anti-inflammatory drops) to prevent infection and reduce swelling.
• Advise against rubbing or pressing on the affected eye.
• Educate the patient to report any signs of complications, such as severe pain, vision loss, or increased redness, to their ophthalmologist immediately.

✘Incorrect answer options:

Over-the-counter eye drops can help manage redness and irritation. While OTC drops may help with minor irritation, they are generally not recommended post-surgery unless specifically advised by the surgeon. Prescribed antibiotic and anti-inflammatory eye drops are the standard to reduce infection risk and promote healing.

Special cataract glasses will be required. Cataract glasses are not typically necessary after modern cataract surgery because intraocular lens implants correct vision. Temporary sunglasses may be recommended to reduce light sensitivity.

A prescribed medication will be necessary to manage post-operative pain. Pain is usually minimal after cataract surgery and can often be managed with over-the-counter analgesics like acetaminophen, if needed. Severe pain is uncommon and may indicate complications requiring immediate attention.