NCLEX- PN Practice Exam 3

EXPLANATION

✔Correct answer:

A diet high in calories but low in fat. The most appropriate diet for a client recovering from pancreatitis is one that is high in calories but low in fat. Pancreatitis involves inflammation of the pancreas, and a high-fat diet can exacerbate symptoms by stimulating the pancreas to release digestive enzymes, leading to further irritation and delayed healing. A high-calorie diet is important to meet the client’s energy needs, as pancreatitis can lead to malnutrition due to decreased enzyme production and impaired digestion. Emphasizing low-fat foods helps reduce pancreatic stimulation and supports recovery.

In pancreatitis, the pancreas becomes inflamed, leading to impaired secretion of digestive enzymes. High-fat intake increases the demand for pancreatic lipase, exacerbating symptoms like abdominal pain, nausea, and diarrhea. A low-fat diet reduces this stress while still providing adequate energy and nutrients for healing. Protein intake should also be adequate to support tissue repair and recovery.

Think of the pancreas as a machine that is temporarily out of order. A high-fat diet is like overloading the machine with tasks it can't handle, while a low-fat, high-calorie diet gives it the "rest" it needs while still fueling the body.

Nurses play a vital role in educating clients on dietary adjustments to promote recovery from pancreatitis.

• Encourage small, frequent meals to reduce the workload on the pancreas.
• Promote a diet rich in lean proteins (e.g., chicken, fish, tofu) and complex carbohydrates (e.g., whole grains, fruits, vegetables).
• Avoid high-fat foods such as fried foods, full-fat dairy, and fatty cuts of meat.
• Monitor for signs of malabsorption, such as steatorrhea (fatty stools), which may indicate the need for pancreatic enzyme supplements.
• Encourage adequate hydration and include fat-soluble vitamins (A, D, E, and K) as these may be deficient due to impaired fat digestion.

✘Incorrect answer options:

A diet low in calories and carbohydrates: A low-calorie diet would not meet the energy needs of a client recovering from pancreatitis, and carbohydrates are essential as an energy source. This option is not suitable for recovery or preventing malnutrition.

A diet high in protein and fat: While protein is essential for recovery, a high-fat diet would exacerbate pancreatitis symptoms by overstimulating the pancreas, delaying healing and worsening outcomes.

A diet low in protein but high in carbohydrates: Protein is vital for tissue repair and healing, and a diet low in protein would not support recovery. While carbohydrates are an important energy source, they cannot replace the essential role of protein.

EXPLANATION

✔Correct answer:

Apply a heating pad to your joints for 5-10 minutes before getting up. Applying heat to the joints is an effective way to reduce morning stiffness in clients with rheumatoid arthritis (RA). Heat therapy helps increase blood flow to the affected areas, relaxes stiff muscles, and improves joint mobility. Morning stiffness is a hallmark symptom of RA due to the accumulation of inflammatory substances in the joints overnight. Using a heating pad or taking a warm shower loosens the joints, making movement easier and less painful.

Rheumatoid arthritis is an autoimmune disease characterized by chronic inflammation of the synovial joints. Overnight inactivity allows inflammatory processes to dominate, leading to joint stiffness and pain upon waking. Heat application counteracts these effects by relaxing muscles, dilating blood vessels, and promoting joint flexibility.

Imagine a frozen rubber band (stiff joints) that needs to be warmed before it can stretch properly. Applying heat softens the rubber band (joints), allowing it to move more freely without snapping (pain).

Nurse Sophie can educate Ms. Lewis on various self-care strategies to manage morning stiffness effectively and maintain joint health.

• Advise using a moist heating pad, warm compress, or taking a warm shower in the morning to reduce stiffness and prepare the joints for movement.
• Encourage incorporating gentle range-of-motion exercises or stretches after applying heat to maintain flexibility and reduce stiffness further.
• Educate on balancing rest and activity to prevent joint strain while maintaining mobility.
• Discuss the importance of proper positioning during sleep, such as using supportive pillows to reduce joint stress.
• Advocate for adherence to prescribed medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or disease-modifying antirheumatic drugs (DMARDs), to control inflammation and symptoms.

✘Incorrect answer options:

"Try soaking your hands in cold water for 15 minutes each morning.": Cold therapy is beneficial for reducing acute inflammation and swelling during RA flares, but it is not effective for relieving morning stiffness. Cold application tends to worsen stiffness by reducing blood flow and tightening the muscles.

"Perform gentle stretching exercises as soon as you wake up.": While stretching is important for maintaining joint mobility, it should be done after applying heat. Stretching cold, stiff joints immediately upon waking may cause discomfort or injury.

"Rest in bed for an extra hour before starting your day.": Prolonged rest can worsen stiffness and joint discomfort. Gentle movement and heat application are more effective for reducing morning stiffness and preparing the joints for activity.

EXPLANATION

✔Correct answer:

Joint swelling, inflammation, and fluid accumulation. Polymigratory arthritis is a hallmark feature of rheumatic fever, characterized by joint swelling, redness, warmth, pain, and fluid accumulation (inflammation). This type of arthritis commonly affects large joints such as the knees, ankles, elbows, and wrists, and it "migrates" from one joint to another over time. Each affected joint typically resolves within a few days, but the arthritis may move to another joint, reflecting the migratory nature of the condition.

Rheumatic fever is an inflammatory disease caused by an abnormal immune response to Group A Streptococcus infection (e.g., strep throat). The immune system mistakenly attacks the synovial tissue in the joints, causing inflammation. Polymigratory arthritis is often the first manifestation of rheumatic fever and is highly responsive to anti-inflammatory treatments, such as aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs).

Think of joint inflammation in polymigratory arthritis as a spotlight moving from one stage (joint) to another. While one stage lights up (swells and inflames), another may go dark (resolve).

Nurse Megan should carefully assess and document Alex's symptoms while addressing discomfort and collaborating on treatment plans.

• Assess for signs of arthritis, such as joint swelling, tenderness, redness, warmth, and limited range of motion.
• Administer prescribed anti-inflammatory medications, such as aspirin or NSAIDs, to reduce inflammation and pain.
• Monitor for other symptoms of rheumatic fever, including carditis (heart inflammation), Sydenham’s chorea, subcutaneous nodules, and erythema marginatum (rash).
• Encourage rest to minimize joint strain and discomfort while inflammation resolves.
• Educate the family about the importance of completing the full course of antibiotics to eradicate Group A Streptococcus and prevent recurrence.

✘Incorrect answer options:

Uncoordinated movements of the limbs and facial grimacing: This finding describes Sydenham’s chorea, another major manifestation of rheumatic fever that affects the central nervous system. While important, it does not indicate polymigratory arthritis.

Painless nodules over the extensor surfaces of the joints: Subcutaneous nodules are another potential feature of rheumatic fever. However, these nodules are painless and not associated with joint swelling or inflammation, making them distinct from polymigratory arthritis.

Light red, irregular rash on the back and abdomen: This describes erythema marginatum, a skin rash seen in rheumatic fever. The rash consists of flat, painless, reddish-pink, and serpiginous (wavy) lesions, but it does not involve joint inflammation or swelling.

EXPLANATION

✔Correct answer:

A noticeable increase in urinary output. A noticeable increase in urinary output is a desired outcome of Digoxin (Lanoxin) therapy in clients with congestive heart failure (CHF). Digoxin improves the heart's contractility by increasing the force of myocardial contraction (positive inotropic effect), which enhances cardiac output. With improved cardiac output, renal perfusion increases, leading to better kidney function and increased urinary output. This reduction in fluid retention helps alleviate symptoms of heart failure, such as edema and pulmonary congestion.

Congestive heart failure is characterized by the heart's inability to pump blood effectively, leading to decreased renal perfusion and fluid retention. By strengthening myocardial contractions, Digoxin helps the heart pump more efficiently, improving circulation to vital organs such as the kidneys. The resulting diuresis helps reduce systemic congestion and improves the client’s overall condition.

Think of the heart as a weak pump and the kidneys as filters that rely on water pressure to function. When the pump is weak (heart failure), the water doesn’t flow to the filters. Digoxin strengthens the pump, restoring water pressure and allowing the filters (kidneys) to work efficiently again, resulting in increased urine output.

Nurse Clara should monitor and educate the client on the effects of Digoxin to ensure therapeutic benefits and minimize risks.

• Monitor for increased urinary output, reduced peripheral or pulmonary edema, and improved exercise tolerance as signs of effective therapy.
• Regularly assess vital signs, including apical pulse, before administering Digoxin. Withhold the medication if the pulse is below 60 beats per minute and notify the healthcare provider.
• Monitor for signs of Digoxin toxicity, such as nausea, vomiting, confusion, visual disturbances (e.g., seeing halos), or arrhythmias.
• Evaluate electrolyte levels, particularly potassium, as hypokalemia increases the risk of Digoxin toxicity.
• Educate the client and caregivers about medication adherence and the importance of reporting any unusual symptoms.

✘Incorrect answer options:

The client’s weight remains stable: Although weight stability is a positive sign in heart failure management, it does not specifically reflect the therapeutic effect of Digoxin. Weight stability is more directly influenced by diuretic therapy and overall fluid balance.

An improvement in the client’s appetite: Improved appetite could occur as a secondary effect of better overall health due to heart failure management. However, this is not a primary indicator of Digoxin's effectiveness.

Worsening of pedal edema: Worsening edema indicates ineffective management of heart failure or fluid retention, suggesting that the therapy is not achieving its intended outcome. Edema should decrease with effective treatment.

EXPLANATION

✔Correct answer:

Hypotension or low blood pressure. Hypotension is a hallmark sign of acute adrenal crisis. This condition, also known as Addisonian crisis, occurs due to a severe deficiency of cortisol and often aldosterone, hormones produced by the adrenal glands. Cortisol is critical for maintaining blood pressure by regulating vascular tone and enhancing the effects of catecholamines. Aldosterone regulates sodium and water retention, which helps maintain blood volume. When these hormones are deficient, blood pressure drops, potentially leading to shock if untreated.

In acute adrenal crisis, a sudden lack of cortisol and aldosterone causes a cascade of symptoms. Hypotension arises due to decreased vascular tone, reduced blood volume from sodium loss, and dehydration. The body’s inability to respond adequately to stress exacerbates the condition, making hypotension one of the most serious and observable manifestations.

Think of cortisol and aldosterone as the "valves" controlling a water system. Without them, the system loses pressure (blood pressure), leading to low flow (hypotension) and instability in the system (shock).

Nurse Carla should prioritize immediate interventions and monitor for other signs of adrenal crisis to prevent progression to shock.

• Administer prescribed corticosteroids (e.g., hydrocortisone) promptly to replace deficient hormones and stabilize the client’s condition.
• Initiate fluid resuscitation with intravenous saline or dextrose solutions to correct dehydration and hypoglycemia, both of which commonly accompany adrenal crisis.
• Monitor vital signs closely, particularly blood pressure and heart rate, to assess the effectiveness of treatment.
• Observe for additional signs of adrenal crisis, such as severe fatigue, abdominal pain, nausea, vomiting, and confusion.
• Educate the client and family on the importance of adhering to prescribed corticosteroid therapy and recognizing early signs of adrenal insufficiency to prevent future crises.

✘Incorrect answer options:

A slow and regular pulse rate: Acute adrenal crisis is typically associated with tachycardia (increased heart rate) as a compensatory response to hypotension. A slow pulse is not a typical finding in this condition.

Skin that is warm and flushed: Skin changes in adrenal crisis are more likely to include pallor or cool, clammy skin due to reduced blood perfusion and shock. Warm and flushed skin is not characteristic of this condition.

Increased frequency of urination: Increased urination might be associated with conditions like diabetes mellitus or diabetes insipidus, not adrenal crisis. In adrenal crisis, dehydration due to aldosterone deficiency may actually lead to decreased urine output in severe cases.

EXPLANATION

✔Correct answer:

A diet high in fat with refined carbohydrates. A diet high in fat and refined carbohydrates is strongly associated with an increased risk of developing colorectal cancer. High-fat diets, especially those rich in saturated fats and processed meats, can lead to the production of carcinogenic compounds during digestion. Refined carbohydrates, such as sugar and white flour, contribute to insulin resistance and chronic inflammation, both of which are risk factors for colorectal cancer. This dietary pattern also lacks adequate fiber, which is protective against colorectal cancer by promoting healthy bowel movements and reducing the time that potential carcinogens remain in the colon.

High-fat diets can stimulate the production of bile acids, which, when broken down in the colon, form secondary bile acids that may damage the colon's lining and promote cancerous changes. Refined carbohydrates contribute to hyperinsulinemia, which can promote cell proliferation and inhibit apoptosis (programmed cell death), increasing the likelihood of malignant growths in the colon.

Think of your colon as a highway. A high-fat, low-fiber diet is like clogging the highway with heavy traffic (toxic waste and carcinogens) that sits for too long, leading to damage (cancer risk). A fiber-rich diet, on the other hand, is like having traffic moving smoothly, clearing out waste quickly and efficiently.

Nurses play a pivotal role in cancer prevention by educating patients about dietary modifications and healthy lifestyle choices.

• Encourage a diet rich in fruits, vegetables, whole grains, and legumes, which provide fiber and antioxidants that reduce cancer risk.
• Advise patients to limit red meat, processed meats, and high-fat foods, as these are linked to colorectal cancer.
• Promote regular physical activity, which helps regulate body weight and reduces cancer risk.
• Educate about the importance of regular colorectal cancer screenings, especially for individuals at high risk or over the age of 50.
• Discuss ways to reduce refined carbohydrate intake, such as replacing white bread with whole grain options and minimizing sugary snacks and beverages.

✘Incorrect answer options:

A diet low in protein with complex carbohydrates: This type of diet is not associated with an increased risk of colorectal cancer. In fact, complex carbohydrates, such as whole grains and vegetables, are protective due to their high fiber content, which promotes colon health.

A diet high in protein with simple carbohydrates: While excessive protein intake (especially from red or processed meats) can increase colorectal cancer risk, the key dietary factor here is the combination of high fat and refined carbohydrates, not just protein alone.

A diet low in carbohydrates with complex proteins: Low-carbohydrate diets are not directly linked to colorectal cancer risk. The lack of protective fiber in such diets could theoretically increase risk, but this is less significant compared to the detrimental effects of a high-fat, refined carbohydrate diet.

EXPLANATION

✔Correct answer:

Request the physician to order a different form of the medication. Clients with esophageal varices are at risk for rupture and bleeding due to the fragile nature of the varices. Administering medications in capsule or tablet form can cause irritation or damage to the esophagus if the medication gets stuck or if the client experiences difficulty swallowing. Nurse Jenna should request that the physician prescribe an alternative form of the medication, such as a liquid suspension, which is safer for clients with esophageal varices as it reduces the risk of esophageal irritation or injury.

Esophageal varices are dilated veins in the lower esophagus, typically caused by portal hypertension related to liver disease. The varices have thin walls and are prone to rupture, which can result in life-threatening bleeding. Any mechanical or chemical irritation, including pills or capsules, could increase the risk of bleeding.

Imagine a water balloon filled to its limit (esophageal varices). If you press a hard object (like a capsule) against it, the balloon is at higher risk of bursting. Using a liquid instead avoids this pressure.

Nurses should ensure medications are administered safely for clients with esophageal varices to minimize risks.

• Request liquid formulations of medications when possible to prevent esophageal irritation.
• Educate clients on the importance of avoiding foods or medications that could irritate or mechanically damage the esophagus.
• Monitor for signs of variceal bleeding, such as hematemesis (vomiting blood) or melena (black, tarry stools).
• Position the client upright during and after medication administration to facilitate swallowing and reduce esophageal irritation.
• Collaborate with the healthcare provider and pharmacy to ensure all medications prescribed are in a safe form for clients with varices.

✘Incorrect answer options:

Administer the medication as prescribed: Administering a capsule without considering the risk of esophageal irritation or injury is unsafe for clients with esophageal varices. Alternative formulations should be sought.

Provide extra water to assist with swallowing: While giving extra water may help some clients swallow capsules, it does not eliminate the risk of mechanical irritation to the esophageal varices. This option does not address the specific risks associated with varices.

Administer the medication alongside an antacid: Antacids may help reduce acid-related irritation, but they do not prevent the mechanical irritation caused by capsules. Additionally, antacids are not indicated to mitigate the risks specific to esophageal varices and could interfere with the absorption of some medications.

EXPLANATION

✔Correct answer:

A history of combined alcohol and tobacco use. The most significant factor contributing to the development of laryngeal cancer is the combined use of alcohol and tobacco. Both substances contain carcinogens that cause genetic mutations in the epithelial cells lining the larynx, which can lead to malignancy. When used together, alcohol and tobacco have a synergistic effect, significantly increasing the risk of laryngeal cancer compared to using either substance alone. This combination damages the mucosa of the larynx, facilitates the entry of carcinogens, and interferes with the repair of damaged DNA.

Tobacco smoke introduces carcinogenic substances, such as nitrosamines and polycyclic aromatic hydrocarbons, into the respiratory system. Alcohol acts as a solvent that enhances the absorption of these carcinogens, increasing their carcinogenic potential. The chronic irritation and inflammation caused by these substances promote abnormal cell proliferation and dysplasia, leading to cancerous changes.

Imagine alcohol as a "key" that unlocks the door for harmful chemicals in tobacco to enter and damage the body's cells. When used together, they create the perfect storm for cancer development.

Nurse Mia should assess for modifiable risk factors and educate the client on strategies to reduce further harm and improve outcomes.

• Educate the client on the importance of tobacco and alcohol cessation, which can significantly reduce the risk of cancer recurrence or progression.
• Refer the client to support programs, such as smoking cessation groups or alcohol rehabilitation services, as appropriate.
• Promote routine follow-ups for cancer screening and monitoring of laryngeal health.
• Advise the client to avoid additional irritants, such as secondhand smoke and environmental pollutants.
• Collaborate with the healthcare team to manage symptoms and address psychosocial concerns related to the diagnosis.

✘Incorrect answer options:

A genetic predisposition due to a family history of laryngeal cancer: While a genetic predisposition may play a role in some cancers, laryngeal cancer is not primarily hereditary. Environmental and lifestyle factors, such as alcohol and tobacco use, are far more significant in its development.

Long-term exposure to harmful fumes: Prolonged exposure to harmful fumes (e.g., asbestos, wood dust, industrial chemicals) can increase the risk of laryngeal cancer but is not as significant a risk factor as combined alcohol and tobacco use. Occupational exposure is more commonly linked to cancers like mesothelioma or lung cancer.

Regular straining or overuse of the vocal cords: Chronic overuse of the vocal cords, such as from speaking loudly or singing, can lead to benign conditions like vocal cord nodules or polyps. However, it is not a significant risk factor for laryngeal cancer.

EXPLANATION

✔Correct answer:

Contagion begins 1 day prior to the rash and lasts until all lesions have crusted over. Varicella (chickenpox) is highly contagious and spreads through respiratory droplets or direct contact with the fluid from the vesicular lesions. Contagion begins approximately 1–2 days before the appearance of the rash and lasts until all lesions have formed crusts. During this period, the virus can spread easily, especially in close-contact environments. Once all lesions have crusted over, the client is no longer contagious, even though the scabs may remain for several days or weeks.

Varicella is caused by the varicella-zoster virus (VZV). The virus replicates in the respiratory tract and spreads to the skin, where it forms the characteristic rash. The rash progresses through stages: macules, papules, vesicles, and crusted lesions. The vesicular stage is when the lesions contain infectious fluid that can transmit the virus.

Think of chickenpox like wet paint on a surface. While the paint (virus) is still wet (vesicles), it can spread to others. Once it dries and forms a crust (scabs), it no longer spreads.

Nurse Rachel should educate Jake's parents about measures to reduce the risk of transmission and provide supportive care for Jake's recovery.

• Instruct the parents to keep Jake at home and away from others until all lesions have crusted over, typically about 5–7 days after the rash first appears.
• Advise against scratching the lesions to prevent secondary bacterial infection or scarring. Recommend trimming Jake’s nails and using mittens if needed.
• Encourage the use of soothing measures, such as cool oatmeal baths or topical calamine lotion, to relieve itching.
• Monitor for signs of complications, such as high fever, difficulty breathing, or signs of superinfection, and seek medical attention if these occur.
• Explain the importance of vaccination for preventing varicella in siblings or other household contacts who may not yet be immune.

✘Incorrect answer options:

Contagion begins 1 day before the rash starts and lasts until vesicles appear: This is incorrect because the contagious stage includes both the vesicular and crusting stages. Contagion does not stop when vesicles form; it lasts until all lesions have crusted.

Contagion continues through both the vesicular and crusting stages of the lesions: This is partially correct but misleading. The contagious stage ends when all lesions have crusted. Once crusts form, the client is no longer contagious, even if scabs remain.

Contagion starts when the rash appears and ends when the rash completely disappears: Contagion starts 1–2 days before the rash appears, not when the rash is visible. Additionally, the rash does not need to completely disappear (scabs may remain) for the client to no longer be contagious.

EXPLANATION

✔Correct answer:

Giving the infant a pacifier to soothe her. After cleft lip repair, giving a pacifier should be avoided because sucking motions can put stress on the surgical site and potentially disrupt the sutures or cause irritation. Protecting the integrity of the surgical repair is crucial during the healing process. Using objects like pacifiers or bottles with firm nipples can create pressure on the incision, increasing the risk of complications such as wound dehiscence (reopening of the wound) or infection.

The priority after cleft lip repair is to maintain the surgical site intact while ensuring the infant is comfortable and hydrated. Non-sucking methods of soothing, feeding, and distraction should be employed to prevent strain on the repaired lip.

Imagine trying to mend a torn piece of fabric. If you keep pulling or stretching the fabric (like sucking on a pacifier), the stitches could break, and the tear may worsen. The same principle applies to the surgical repair of the lip.

Nurses must take steps to ensure post-operative safety and healing while supporting the infant’s comfort.

• Position the baby in an upright or semi-sitting position to reduce pressure on the surgical site and support proper breathing.
• Avoid using pacifiers or bottle nipples; instead, use alternative feeding methods, such as a syringe with a soft catheter or a special feeding bottle designed for post-cleft repair.
• Gently clean the surgical site as per protocol, and monitor for signs of infection, such as redness, swelling, or drainage.
• Use elbow restraints ("no-nos") as ordered to prevent the infant from touching or rubbing the surgical area.
• Provide non-sucking comfort measures such as holding, rocking, or engaging the infant with toys or a mobile for distraction.

✘Incorrect answer options:

Holding the infant in her arms: Holding the infant provides emotional comfort and bonding without placing strain on the surgical site. It also helps the nurse monitor the baby's well-being closely.

Using a mobile to distract and calm the infant: Using a mobile is a safe and effective way to soothe the baby without involving sucking or pressure on the lip repair.

Offering sterile water for hydration: Providing sterile water for hydration is essential for maintaining fluid balance and soothing the baby. It does not involve sucking and is safe when given using appropriate feeding techniques, such as a soft syringe.

EXPLANATION

✔Correct answer:

A noticeable pulsation in the periumbilical region. A noticeable pulsation in the periumbilical region is a classic finding associated with an abdominal aortic aneurysm (AAA). This pulsation is caused by the abnormal dilation of the abdominal aorta, which allows blood flow to create a palpable pulsating mass. Clients with AAA may not always exhibit symptoms, but when present, the pulsating mass is a hallmark physical finding that can assist in the diagnosis.

An abdominal aortic aneurysm develops when the wall of the abdominal aorta weakens, leading to dilation or ballooning of the vessel. The force of blood flow against the weakened area causes the pulsating sensation that can often be palpated or seen in the abdomen. If the aneurysm grows large enough, it may cause symptoms like abdominal or back pain due to pressure on surrounding tissues or organs.

Think of an AAA as a weak spot in a garden hose. When water flows through, the weakened area bulges and pulsates with the flow of water, similar to the pulsation of the aneurysm in the abdominal aorta.

Nurse Sam should prioritize safe assessment practices and ensure timely interventions to prevent complications, such as rupture, which is life-threatening.

• Avoid deep palpation of the abdomen, as this could increase the risk of aneurysm rupture.
• Assess for additional symptoms such as dull or throbbing abdominal pain, back pain, or signs of impending rupture (e.g., sudden severe pain, hypotension, or shock).
• Monitor vital signs closely, especially for changes in blood pressure or heart rate that might indicate complications.
• Collaborate with the healthcare team to ensure timely imaging studies (e.g., abdominal ultrasound or CT scan) to confirm the diagnosis and determine the size and risk of rupture.
• Educate the client about the importance of regular monitoring for AAA if diagnosed, and encourage risk reduction strategies, such as smoking cessation and blood pressure control.

✘Incorrect answer options:

Numbness or loss of sensation in the lower extremities: While an AAA could theoretically cause symptoms of ischemia in the lower extremities if it compresses nearby vessels, numbness is not a typical symptom. This is more commonly associated with peripheral vascular disease or nerve compression.

Back pain that improves when standing upright: Back pain related to AAA is often described as dull, constant, or throbbing, and it is usually caused by the aneurysm pressing on nearby structures. It does not typically improve with positional changes.

A reduction in urinary output: While an AAA located near the renal arteries might affect kidney perfusion in rare cases, reduced urinary output is not a common or primary symptom of AAA. It could indicate other issues, such as kidney failure or shock from aneurysm rupture.

EXPLANATION

✔Correct answer:

Repeating words or phrases spoken by others. Echolalia is a speech pattern characterized by the repetition of words or phrases spoken by others. It is often seen in clients with schizophrenia, autism spectrum disorder, or certain neurological conditions. In schizophrenia, echolalia is usually a sign of disorganized thought processes or impaired communication. The client may mimic what they hear without understanding or intending to respond meaningfully.

In schizophrenia, disordered brain activity, particularly in the areas responsible for language processing and executive functioning (such as the frontal lobe), can lead to communication abnormalities like echolalia. The repetition may be involuntary or a way for the client to process or express themselves when their ability to generate spontaneous language is impaired.

Imagine a parrot repeating phrases it hears but not engaging in meaningful conversation. Similarly, a person with echolalia repeats words or phrases without necessarily understanding or intending to communicate them meaningfully.

Nurse Clara should approach the client with understanding and employ strategies to promote effective communication.

• Acknowledge the behavior without drawing negative attention to it, as it may increase the client's anxiety.
• Use simple, clear, and concise language to minimize confusion and reduce the likelihood of echolalia.
• Encourage alternative communication methods, such as writing or nonverbal gestures, if speech patterns are severely disorganized.
• Assess for underlying triggers, such as stress or overstimulation, that may exacerbate disorganized speech or echolalia.
• Collaborate with the healthcare team, including speech therapists, to implement strategies that improve the client’s communication skills over time.

✘Incorrect answer options:

Speaking in rhyming patterns: This behavior, known as clang associations, involves speaking in a way where words are chosen based on their sound or rhyme rather than their meaning. While clang associations can occur in schizophrenia, they are not the same as echolalia.

Adding unnecessary details to conversations: This is known as circumstantiality, where the individual includes excessive, unnecessary details but eventually returns to the original point. It is not characteristic of echolalia.

Creating new words with unique meanings: This behavior is called neologism and is another speech abnormality observed in schizophrenia, where clients invent words that have meaning only to them. Neologisms are distinct from echolalia, which involves repetition of existing speech.

EXPLANATION

✔Correct answer:

Cream of tomato soup and crackers. The most likely cause of symptom recurrence in Ms. Harper, who has celiac disease, is the cream of tomato soup and crackers. Many commercially prepared soups and crackers contain gluten, a protein found in wheat, barley, and rye. Gluten ingestion in clients with celiac disease triggers an immune-mediated reaction in the small intestine, leading to inflammation, villous atrophy, and malabsorption. This results in symptoms such as diarrhea, bloating, abdominal pain, and fatigue.

In celiac disease, the ingestion of gluten causes an autoimmune response that damages the villi of the small intestine, impairing nutrient absorption. Even small amounts of gluten can trigger symptoms and intestinal damage, making strict avoidance essential. Processed foods, like soups and crackers, often contain hidden sources of gluten as thickeners or fillers, which can exacerbate symptoms.

Imagine the small intestine's villi as a carpet. Gluten acts like scissors, cutting the carpet fibers (villi) and reducing its ability to absorb nutrients effectively.

Nurse Lily should educate Ms. Harper on how to avoid gluten-containing foods and manage her symptoms effectively.

• Educate the client on reading food labels carefully to identify hidden sources of gluten in processed foods (e.g., soups, sauces, dressings, and seasonings).
• Encourage adherence to a strict gluten-free diet by consuming naturally gluten-free foods such as fresh fruits, vegetables, lean proteins, rice, and gluten-free grains like quinoa.
• Advise avoiding cross-contamination by using separate utensils, cutting boards, and cookware for gluten-free and gluten-containing foods.
• Collaborate with a dietitian to develop a comprehensive gluten-free meal plan tailored to the client's preferences and nutritional needs.
• Monitor for long-term complications of celiac disease, such as nutritional deficiencies (iron, calcium, folate, vitamin D) or osteoporosis, and recommend appropriate supplementation if needed.

✘Incorrect answer options:

Tossed salad with oil and vinegar dressing: A tossed salad with oil and vinegar is naturally gluten-free and is unlikely to exacerbate symptoms unless contaminated with croutons or a gluten-containing dressing.

Baked potato with sour cream and chives: Baked potatoes and sour cream are gluten-free and safe for individuals with celiac disease. However, toppings or additives like gravies or certain seasonings might pose a risk if not gluten-free, but none are mentioned here.

Mixed fruit and yogurt: Fresh fruit and yogurt are gluten-free. While some flavored yogurts may contain gluten, this is uncommon, and there is no indication in this option that the yogurt contained gluten.

EXPLANATION

✔Correct answer:

Feelings of low self-worth. Delusions of grandeur, such as believing one is the Son of God, are often rooted in feelings of low self-worth. Clients with these delusions may adopt an exaggerated sense of importance or identity as a way to compensate for feelings of inadequacy, powerlessness, or a lack of control in their lives. This defense mechanism serves to protect their ego and self-esteem from overwhelming negative emotions. Delusions of grandeur are a common symptom in conditions like schizophrenia or bipolar disorder during manic phases.

In psychiatric conditions such as schizophrenia, alterations in brain chemistry (e.g., dopamine dysregulation) and abnormal functioning of the frontal and temporal lobes can distort reality perception, leading to delusions. Delusions of grandeur specifically may emerge as a coping mechanism to counteract deep-seated feelings of inferiority or insecurity.

Imagine someone building a tall, flashy tower (the delusion) to hide a crumbling foundation (low self-worth). The grandeur of the tower distracts from the insecurity underneath.

Nurse Jamie should approach Mr. Allen with empathy and understanding while ensuring his safety and fostering a therapeutic relationship.

• Avoid directly challenging or confronting the delusion, as this may increase the client’s defensiveness or mistrust.
• Provide reality orientation by focusing on the present moment and redirecting attention to concrete tasks or topics.
• Establish a calm, supportive environment to reduce stress, which can exacerbate delusions.
• Encourage participation in structured activities that promote self-esteem and social interaction without reinforcing the delusion.
• Collaborate with the healthcare team to ensure appropriate treatment, such as antipsychotic medications and psychotherapy, to address underlying symptoms and improve coping mechanisms.

✘Incorrect answer options:

A profound religious experience: While profound religious experiences can influence beliefs, delusions of grandeur are not the result of a genuine religious experience. They stem from distorted perceptions of reality caused by underlying psychiatric or neurochemical issues.

A reaction to a recent stressful event: Stressful events can trigger psychotic symptoms or exacerbate existing mental health conditions, but they do not directly explain the formation of delusions of grandeur. The belief in being the Son of God is more likely linked to underlying feelings of low self-worth or a psychiatric condition.

Intense, overwhelming anxiety: While anxiety can contribute to the development of psychosis in some cases, delusions of grandeur are not typically a direct result of anxiety. Anxiety-related delusions are more often paranoid in nature, such as beliefs of being watched or persecuted.

EXPLANATION

✔Correct answer:

To loosen secretions and alleviate laryngospasms. The primary purpose of using a cool, high-humidity tent for a child with croup is to loosen secretions and reduce airway inflammation, which helps alleviate laryngospasms (spasms of the vocal cords causing breathing difficulties). The humidified air moisturizes the respiratory tract, making it easier to clear secretions and reducing the characteristic barking cough, stridor, and respiratory distress associated with croup. The cool air also helps soothe the inflamed mucosa of the upper airway.

Croup (laryngotracheobronchitis) is a viral infection that causes inflammation and swelling of the larynx, trachea, and bronchi, leading to airway obstruction. This results in stridor (a high-pitched breathing sound), a barking cough, and difficulty breathing. Humidified air reduces mucosal dryness, loosens thick secretions, and decreases airway resistance, providing symptomatic relief.

Imagine the airway as a dry, sticky pipe. Adding moisture through the humidified tent acts like a mist that softens the dryness and clears the stickiness, making it easier for air to flow.

Nurse Clara should monitor Emma closely while providing supportive care to ensure the high-humidity tent is effective.

• Monitor respiratory status, including rate, effort, and presence of stridor or retractions, to assess for improvement or worsening of symptoms.
• Encourage fluid intake (if the child can drink safely) to prevent dehydration and further thin secretions.
• Reassure parents about the benefits of the high-humidity tent and how it helps alleviate symptoms without requiring invasive procedures.
• Ensure the child’s comfort by keeping the tent properly sealed while allowing interaction with parents to minimize anxiety.
• Educate parents about other at-home measures, such as using a cool-mist humidifier or exposing the child to cool outdoor air during acute episodes of croup.

✘Incorrect answer options:

To reduce insensible water loss: While humidified air may slightly reduce insensible water loss, this is not the primary purpose of the high-humidity tent. The intervention is focused on respiratory symptom relief rather than hydration concerns.

To create a moist environment with 30% oxygen: A high-humidity tent typically uses room air, not supplemental oxygen, unless specifically indicated. Its primary function is to humidify the air rather than deliver oxygen.

To prevent dehydration and help lower the fever: Although hydration is important in croup management, the tent’s primary purpose is not to prevent dehydration or reduce fever. Fever management and fluid intake are addressed through other interventions, such as antipyretics and oral fluids.

EXPLANATION

✔Correct answer:

Numbness and tingling sensations in the extremities. Numbness and tingling sensations in the extremities (referred to as paresthesia) are unique to pernicious anemia due to its association with vitamin B12 deficiency. Vitamin B12 is essential for proper nerve function, and a deficiency can result in demyelination of peripheral nerves and the spinal cord. This neurological manifestation distinguishes pernicious anemia from other types of anemia, such as iron-deficiency anemia or anemia of chronic disease, which do not typically present with neurological symptoms.

Pernicious anemia is caused by a deficiency in vitamin B12 due to the lack of intrinsic factor, a protein necessary for B12 absorption in the gastrointestinal tract. Without adequate B12, there is impaired DNA synthesis in red blood cells (leading to megaloblastic anemia) and disruption of myelin production, which affects nerve conduction. This results in characteristic symptoms like paresthesia, balance issues, and even cognitive impairment in severe cases.

Imagine electrical wires covered with insulation (myelin). Without proper insulation, the wires (nerves) short-circuit, leading to "tingling" or "numb" sensations in the areas they supply.

Nurse Emma should educate the client about pernicious anemia and focus on interventions to address the B12 deficiency and prevent complications.

• Administer vitamin B12 supplementation as prescribed, usually via intramuscular injection for clients with intrinsic factor deficiency.
• Monitor for improvement in neurological symptoms, such as decreased numbness, tingling, or coordination issues.
• Educate the client about the importance of regular B12 supplementation, as pernicious anemia typically requires lifelong treatment.
• Assess for other signs of vitamin B12 deficiency, such as glossitis (inflamed tongue) and fatigue.
• Encourage a diet rich in vitamin B12 for clients who can absorb it, including foods such as meat, eggs, dairy, and fortified cereals.

✘Incorrect answer options:

Shortness of breath following physical activity: Shortness of breath is a common symptom of many types of anemia, including iron-deficiency anemia and anemia of chronic disease, as it reflects the reduced oxygen-carrying capacity of the blood. It is not specific to pernicious anemia.

A heart rate that is faster than usual: Tachycardia (increased heart rate) is a general compensatory response to anemia as the body tries to deliver more oxygen to tissues. This symptom is not unique to pernicious anemia and is seen in many types of anemia.

Episodes of lightheadedness or dizziness: Lightheadedness or dizziness can occur in any type of anemia due to reduced oxygen delivery to the brain. While common, it is not a distinguishing feature of pernicious anemia.

EXPLANATION

✔Correct answer:

Weight gain, fatigue, slowed speech, and a reduced respiratory rate. Clients with hypothyroidism typically present with a range of symptoms caused by a decreased production of thyroid hormones (T3 and T4). These hormones are responsible for regulating the body’s metabolism. In hypothyroidism, the metabolic rate slows down, leading to weight gain, fatigue, slowed speech, and a reduced respiratory rate. Other common symptoms include bradycardia (slow pulse), cold intolerance, dry skin, constipation, and hair thinning.

Hypothyroidism occurs when the thyroid gland fails to produce adequate levels of thyroid hormones. This may result from autoimmune diseases (e.g., Hashimoto’s thyroiditis), iodine deficiency, or surgical removal of the thyroid gland. The reduced metabolic activity slows down nearly all bodily functions, contributing to the characteristic symptoms.

Think of the thyroid gland as the body's thermostat. When the thermostat is set too low (hypothyroidism), everything slows down—metabolism, energy, heart rate, and even speech.

Nurse Ellen should focus on symptom management, client education, and monitoring for complications such as myxedema (a severe form of hypothyroidism).

• Assess vital signs regularly, focusing on bradycardia and a reduced respiratory rate, which may indicate worsening hypothyroidism.
• Monitor for cold intolerance and provide measures to maintain warmth, such as extra blankets or warm clothing.
• Educate the client about adhering to thyroid hormone replacement therapy (e.g., levothyroxine) and taking the medication on an empty stomach for optimal absorption.
• Encourage a balanced diet to address weight concerns and support metabolism, while avoiding high-fat, high-calorie foods.
• Assess for and manage associated symptoms like constipation by increasing dietary fiber and fluid intake.

✘Incorrect answer options:

Slow pulse rate, weight loss, diarrhea, and signs of cardiac failure: While a slow pulse rate is associated with hypothyroidism, weight loss and diarrhea are symptoms of hyperthyroidism (overactive thyroid), not hypothyroidism. Signs of cardiac failure can occur in hypothyroidism but are not typical in early stages.

Rapid pulse, constipation, and protruding eyes: A rapid pulse and protruding eyes (exophthalmos) are characteristic of hyperthyroidism, specifically Graves' disease. Constipation, however, is a symptom of hypothyroidism, but it does not align with the other findings in this option.

Low body temperature, weight loss, and faster breathing: Low body temperature is a symptom of hypothyroidism, but weight loss and faster breathing (tachypnea) are not. These findings are more consistent with hyperthyroidism or other metabolic conditions.

EXPLANATION

✔Correct answer:

Nephritis Nephritis, specifically lupus nephritis, is one of the most significant complications of systemic lupus erythematosus (SLE). Lupus nephritis occurs when the immune system attacks the kidneys, leading to inflammation and impaired kidney function. This complication can range from mild to severe and, if untreated, may progress to kidney failure. Up to 50% of people with SLE develop lupus nephritis, making it a critical focus of monitoring and management.

SLE is an autoimmune disease where the immune system mistakenly attacks the body's tissues. In lupus nephritis, immune complexes are deposited in the glomeruli (filtering units of the kidneys), leading to inflammation, proteinuria, hematuria, and potentially decreased glomerular filtration rate (GFR). Persistent kidney damage can lead to chronic kidney disease or end-stage renal disease (ESRD).

Think of the kidneys as coffee filters and immune complexes as coffee grounds. If too many coffee grounds clog the filters, the system becomes overwhelmed, leading to "leaks" (protein in urine) or a backup of waste (kidney dysfunction).

Nurses play a critical role in monitoring SLE clients for signs of nephritis and ensuring timely interventions to prevent long-term complications.

• Monitor for signs of nephritis, including hematuria (blood in urine), proteinuria (foamy urine), edema, and hypertension.
• Encourage compliance with medications such as corticosteroids or immunosuppressants, which reduce kidney inflammation.
• Educate the patient on the importance of routine urine tests and renal function monitoring.
• Advise the client to avoid nephrotoxic drugs or substances and maintain adequate hydration.
• Collaborate with the healthcare team for timely adjustment of treatment based on kidney function test results.

✘Incorrect answer options:

Cardiomegaly: While cardiovascular complications such as pericarditis and myocarditis are common in SLE, cardiomegaly (enlargement of the heart) is not the most significant complication. Lupus nephritis is a more prevalent and life-threatening issue in SLE clients.

Desquamation: Desquamation (peeling of the skin) can occur with certain skin conditions or severe rashes. Although SLE frequently affects the skin (e.g., butterfly rash), desquamation is not a primary or significant complication associated with the disease.

Meningitis: Meningitis is inflammation of the meninges (the protective layers surrounding the brain and spinal cord). While central nervous system involvement (e.g., lupus cerebritis) is possible in SLE, lupus nephritis is a more common and significant complication requiring close monitoring.

EXPLANATION

✔Correct answer:

Playing with a ball. Playing with a ball is the most appropriate activity for promoting gross motor skill development in a 2-year-old child like Lily. Gross motor skills involve the use of large muscle groups for activities such as running, jumping, throwing, or kicking. At this age, children are developing coordination, balance, and control of their larger muscles. Activities like throwing, catching, or kicking a ball help strengthen these skills while encouraging physical activity and play.

By 2 years old, toddlers typically demonstrate abilities such as running, climbing stairs (with assistance), and kicking or throwing a ball. These activities are crucial for improving coordination and muscle strength as part of gross motor development.

Think of gross motor skills as building the foundation of a house. Activities like playing with a ball help strengthen the "framework" (large muscles) needed for more advanced skills, such as running or jumping.

Nurse Amy should encourage activities that promote physical development while ensuring safety and age-appropriate challenges for the child.

• Encourage activities like throwing, catching, or kicking a ball, which support coordination, strength, and balance.
• Educate parents about the importance of providing opportunities for free play to enhance gross motor development.
• Ensure a safe play environment by removing hazards and supervising the child during active play.
• Reassure parents about normal variations in the pace of motor development, as milestones may vary slightly from child to child.
• Monitor for delays in gross motor skills and recommend further evaluation if significant delays are observed.

✘Incorrect answer options:

Using a coloring book and crayons: While coloring promotes fine motor skill development (e.g., finger and hand coordination), it does not support gross motor skills. Fine motor skills typically involve smaller muscle movements.

Stacking building cubes: Stacking cubes also enhances fine motor skills, as it involves hand-eye coordination and precision. It is not a primary activity for gross motor skill development.

Using a swing set: While using a swing set involves some gross motor components, such as holding on and balancing, it is a more passive activity compared to playing with a ball, which requires active engagement of large muscle groups.

EXPLANATION

✔Correct answer:

14 pounds. By 6 months of age, it is expected that a healthy infant will double their birth weight. Since Baby Noah weighed 7 pounds at birth, his expected weight at 6 months would be approximately 14 pounds. This doubling of birth weight is a general guideline for assessing healthy growth and development in infants during the first 6 months of life.

Weight gain in infants follows a predictable pattern during the first year of life:

• Birth to 6 months: Infants typically gain about 5-7 ounces per week and double their birth weight by 6 months.
• 6 to 12 months: The rate of weight gain slows slightly, and infants usually triple their birth weight by 12 months.

Think of a baby’s weight gain as a balloon slowly inflating over time. By 6 months, the balloon has doubled its size, showing that the baby is growing as expected.

Nurse Jenna should educate Baby Noah's parents about growth patterns and provide reassurance about healthy development.

• Reinforce the importance of regular pediatric checkups to monitor weight, height, and head circumference as indicators of growth and development.
• Advise parents to provide adequate nutrition, which typically includes exclusive breastfeeding or formula feeding until about 6 months, and then gradual introduction of complementary foods.
• Discuss developmental milestones that accompany weight gain, such as improved motor skills and increased activity levels, which may influence caloric needs.
• Educate parents to monitor for signs of adequate nutrition, such as steady weight gain, contentment after feedings, and a minimum of 6-8 wet diapers per day.
• Reassure parents that slight variations in growth rates are normal, but encourage them to report significant deviations (e.g., failure to gain weight or excessive weight gain) to their pediatrician.

✘Incorrect answer options:

18 pounds: While this weight may seem reasonable, it exceeds the expected doubling of Baby Noah's birth weight (7 pounds). Infants typically do not gain weight at a rate that results in more than doubling by 6 months unless there are specific factors (e.g., overfeeding, genetic predisposition).

25 pounds: A weight of 25 pounds is much higher than expected for a 6-month-old and may suggest excessive weight gain or another underlying condition requiring medical evaluation.

30 pounds: A weight of 30 pounds is highly unlikely for a 6-month-old. This weight would far exceed normal growth expectations and may indicate overfeeding or a potential medical issue.

EXPLANATION

✔Correct answer:

Fresh tomatoes. Fresh tomatoes are a poor source of iron compared to other options. While they contain some iron, the amount is minimal, and they are not considered a significant dietary source of this nutrient. Additionally, the type of iron in plant-based foods (non-heme iron) found in tomatoes is less readily absorbed by the body than the heme iron from animal sources. Though tomatoes can enhance iron absorption from other foods due to their vitamin C content, they themselves do not provide substantial iron levels.

Iron-deficiency anemia occurs when there is insufficient iron to produce hemoglobin, which is essential for oxygen transport in the blood. Dietary sources of iron, particularly those rich in bioavailable iron, are critical for preventing and managing this condition. Non-heme iron absorption is influenced by enhancers (like vitamin C) and inhibitors (like phytates or calcium) in the diet.

Think of iron-rich foods as different water sources for filling a bucket (iron stores in the body). Tomatoes are like a slow-dripping faucet—while they contribute, they don’t add much compared to a flowing tap (legumes or nuts).

Nurse Mia should educate the client about iron-rich foods and how to enhance dietary iron absorption.

• Encourage consumption of iron-rich foods such as legumes, dried fruits, nuts, fortified cereals, and lean meats.
• Advise pairing iron-rich foods with vitamin C sources (e.g., citrus fruits or tomatoes) to improve non-heme iron absorption.
• Educate the client to avoid consuming iron inhibitors, such as tea, coffee, and calcium-rich foods, with iron-containing meals.
• Assess for any gastrointestinal symptoms that may impair iron absorption, such as celiac disease or chronic inflammation.
• Monitor for improvement in hemoglobin and hematocrit levels as dietary changes are implemented.

✘Incorrect answer options:

Various legumes: Legumes, such as lentils, chickpeas, and beans, are excellent sources of iron and are commonly recommended for individuals with iron-deficiency anemia. They also contain fiber and other nutrients beneficial for overall health.

Assorted dried fruits: Dried fruits like raisins, apricots, and prunes are good sources of iron. They are also high in natural sugars and can serve as a portable snack option to support iron intake.

Mixed nuts: Nuts, such as almonds and cashews, contain moderate amounts of iron and are a good addition to a diet aimed at improving iron levels. They also provide healthy fats and protein, making them a nutritious option overall.

EXPLANATION

✔Correct answer:

Bright red urine containing numerous clots. Bright red urine with numerous clots is an alarming finding in a client recovering from a transurethral prostatectomy (TURP) and should be reported to the doctor immediately. This may indicate active arterial bleeding, which is a serious post-operative complication. While some blood in the urine (hematuria) is expected after TURP due to the nature of the procedure, excessive bleeding characterized by bright red urine with clots can obstruct the urinary catheter or bladder, leading to urinary retention and increased pressure, which may cause further complications.

TURP involves removing part of the prostate gland through the urethra, which can leave raw, healing tissue in the area. Post-operative bleeding occurs when the surgical site is disrupted or if blood vessels fail to clot properly. Bright red blood indicates fresh arterial bleeding, as opposed to darker blood, which is venous in origin. Clots may worsen the situation by obstructing the catheter and interfering with continuous bladder irrigation.

Think of a leaking pipe. A small amount of water leaking (light bleeding) might be manageable, but a steady stream of water (bright red blood) requires immediate attention to prevent further damage.

Nurse Julia should take steps to address the situation while promptly notifying the healthcare provider.

• Check the urinary catheter for patency and ensure continuous bladder irrigation is functioning properly to prevent clot formation and catheter obstruction.
• Measure and document the color and volume of urine output hourly to monitor the bleeding severity and detect any changes.
• Assess the client for additional signs of hypovolemia or hemorrhage, such as hypotension, tachycardia, pallor, or dizziness.
• Temporarily increase the rate of bladder irrigation (if ordered) to dilute and flush out clots and prevent obstruction.
• Notify the healthcare provider immediately to determine if surgical intervention or other measures (e.g., adjusting irrigation, applying traction to the catheter) are required.

✘Incorrect answer options:

An hourly urinary output of 40–50 mL: This output is within the expected range for a client after TURP and indicates adequate renal function. While output should be monitored for trends of decline, this finding does not suggest an urgent complication.

Dark red urine with only a few clots: Dark red urine and a small number of clots are expected in the first 24–48 hours after TURP as the surgical site begins to heal. This does not indicate active arterial bleeding and is not a cause for immediate concern.

Regular requests for pain medication every 4 hours: Pain is common after TURP and is usually related to bladder spasms, catheter irritation, or mild post-operative discomfort. Pain controlled with scheduled medication is expected and does not indicate a serious complication.

EXPLANATION

✔Correct answer:

Wear extra layers of clothing to retain warmth. Clients with hypothyroidism often experience cold intolerance due to a reduced basal metabolic rate caused by insufficient thyroid hormone levels. Wearing extra layers of clothing is a safe and effective way to retain body heat and stay warm. This approach avoids the risks associated with direct heat sources, such as burns, and allows the client to adjust layers as needed for comfort.

Hypothyroidism slows down the metabolic processes, resulting in reduced heat production. Additionally, peripheral vasoconstriction (a response to conserve heat) may cause the client to feel colder, especially in extremities. Layering clothing helps maintain warmth without compromising safety.

Think of your body like a house with poor insulation during the winter. Adding extra layers of clothing is like wrapping the house in blankets, keeping the warmth inside and protecting it from the cold air.

Nurses can support clients with hypothyroidism by offering strategies to address cold intolerance safely and by monitoring for other symptoms of the condition.

• Encourage wearing warm, layered clothing, including thermal undergarments and socks, to maintain body temperature.
• Promote physical activity, as gentle exercise can improve circulation and increase heat production.
• Advise avoiding exposure to extremely cold environments to prevent discomfort or further vasoconstriction.
• Monitor the client for signs of worsening hypothyroidism, such as severe fatigue, weight gain, or depression.
• Reinforce adherence to prescribed thyroid hormone replacement therapy (e.g., levothyroxine) to restore metabolic balance and improve cold intolerance.

✘Incorrect answer options:

Use an electric blanket during the night: While an electric blanket may provide warmth, clients with hypothyroidism may have reduced sensitivity to temperature changes, increasing the risk of burns or overheating. It is not the safest option for managing cold intolerance.

Apply a heating pad to her feet for additional warmth: Heating pads can cause burns if left in place for too long, especially for clients with hypothyroidism, who may have altered sensation or delayed response to heat. Safer, indirect warming methods (like warm socks) are preferred.

Take hot baths in both the morning and evening: Frequent hot baths may temporarily provide warmth but can lead to skin dryness and irritation, which are common issues for clients with hypothyroidism. Additionally, prolonged exposure to hot water can cause excessive heat loss after leaving the bath.

EXPLANATION

✔Correct answer:

Constipation. Constipation is a common side effect of aluminum-based antacids like Basalgel (aluminum carbonate gel). Aluminum compounds can slow down intestinal motility and reduce water content in the stool, leading to difficulty with bowel movements. This side effect is particularly important to monitor in patients who are prone to constipation or have other risk factors, such as a low-fiber diet or reduced physical activity.

Aluminum ions in antacids interact with hydrochloric acid in the stomach to neutralize excess gastric acid, relieving indigestion and heartburn. However, aluminum also binds to phosphate in the gastrointestinal tract, reducing phosphate absorption and altering fluid and electrolyte balance, which contributes to the development of constipation.

Think of aluminum-based antacids as a sponge soaking up fluid in the intestines. If too much fluid is absorbed, the stool becomes dry and hard, leading to constipation.

Nurse Ella should educate Mr. Thompson on strategies to prevent constipation while using aluminum-based antacids and monitor for complications.

• Encourage an increase in dietary fiber (e.g., fruits, vegetables, whole grains) and adequate fluid intake to promote regular bowel movements.
• Advise engaging in regular physical activity, which helps stimulate intestinal motility.
• Monitor for signs of severe or prolonged constipation, and notify the healthcare provider if symptoms persist.
• Educate the client to avoid excessive or prolonged use of aluminum-based antacids, as this can exacerbate constipation and cause other complications, such as hypophosphatemia (low phosphate levels).
• Discuss the possibility of alternating or combining aluminum-based antacids with magnesium-based antacids (with the provider’s guidance) to balance the constipating effects, as magnesium-based antacids can cause diarrhea.

✘Incorrect answer options:

Difficulty with urinary retention: Aluminum-based antacids are not typically associated with urinary retention. This side effect is more commonly seen with medications that have anticholinergic properties.

Diarrhea: Diarrhea is a common side effect of magnesium-based antacids, not aluminum-based antacids. Aluminum tends to slow intestinal motility, leading to constipation instead.

Episodes of confusion: Confusion is not a common side effect of aluminum-based antacids. However, in clients with kidney disease who use aluminum-containing products excessively, aluminum toxicity can occur, potentially causing neurological symptoms like confusion, but this is rare.

EXPLANATION

✔Correct answer:

Periodically lie prone without using a neck pillow. Lying in a prone position (face down) without a neck pillow helps counteract the tendency toward spinal flexion (forward bending) seen in individuals with Parkinson’s disease. This position promotes spinal extension, improves posture, and helps prevent contractures or deformities caused by the flexed posture that often develops as a result of muscle rigidity and bradykinesia (slowness of movement) in Parkinson’s disease. Regularly assuming a prone position can stretch the anterior muscles of the body and maintain alignment of the spine.

Parkinson's disease is characterized by progressive neurodegeneration, leading to muscle rigidity, postural instability, and a stooped posture due to imbalance between flexor and extensor muscle groups. Spinal flexion is a postural abnormality resulting from prolonged flexor muscle activity overpowering extensor muscles, which can worsen mobility, balance, and quality of life if not addressed.

Imagine a flexible ruler that’s left bent for too long—it begins to hold that shape. Periodically straightening it (lying prone) helps it return to its normal shape, just as lying prone helps the spine counteract flexion.

Nurses should encourage physical activities and postural exercises to prevent spinal complications and improve overall functionality for clients with Parkinson’s disease.

• Encourage daily prone positioning for short periods (e.g., 15–30 minutes) to stretch the spine and prevent forward flexion.
• Recommend regular physical therapy and exercises focusing on spinal extension and posture improvement.
• Educate on ergonomics, such as using firm chairs with good lumbar support and avoiding prolonged sitting in flexed positions.
• Advise against using soft, high pillows while sleeping, as these can promote neck flexion and worsen posture.
• Teach relaxation techniques to reduce muscle rigidity, such as deep breathing exercises or warm baths.

✘Incorrect answer options:

Sleep exclusively in the dorsal recumbent position: While lying on the back (dorsal recumbent) might prevent neck flexion, this position does not specifically counteract spinal flexion or promote extension of the spine. Additionally, prolonged use of this position may not adequately stretch the anterior muscles.

Rest on his back (supine) with his head elevated: Sleeping in a supine position with the head elevated may be helpful for clients with breathing or reflux issues, but it does not address spinal flexion. Elevating the head could even contribute to neck or upper spine flexion if not properly supported.

Sleep on his side while keeping his back straight: While sleeping on the side may help maintain alignment, it does not stretch the anterior muscles or counteract spinal flexion caused by Parkinson's disease. This position is not specifically recommended for preventing spinal deformities.