NCLEX- PN Practice Exam 4

EXPLANATION

✔Correct answer:

Relieve the client’s pain effectively. The primary objective of nursing care for a client receiving an opioid analgesic, such as Percocet (oxycodone), is to relieve pain effectively while monitoring for and managing potential side effects. Pain management is a fundamental part of postoperative recovery as unrelieved pain can delay healing, impair mobility, and negatively impact the client’s overall well-being. By effectively managing Mrs. Lopez's pain, Nurse Hannah promotes comfort, facilitates movement, and improves the client’s ability to participate in activities like deep breathing, coughing, and early ambulation, which are essential for preventing complications such as atelectasis or blood clots.

While opioid therapy carries risks such as sedation, respiratory depression, nausea, and constipation, these are manageable with proper monitoring and nursing interventions. Concerns about addiction are valid but should not deter appropriate and effective pain management, especially for short-term postoperative use.

Think of pain as a locked door that prevents the client from healing and moving forward. An opioid analgesic is the key that unlocks the door, allowing the client to focus on recovery rather than being trapped by pain.

While ensuring pain relief, Nurse Hannah should also monitor for opioid-related side effects and implement strategies to minimize risks:

• Assess pain levels regularly using an appropriate pain scale and evaluate the effectiveness of the medication.
• Monitor respiratory status closely, as opioids can cause respiratory depression. Report a respiratory rate below 12 breaths per minute.
• Encourage fluid intake, high-fiber foods, and, if needed, stool softeners to prevent opioid-induced constipation.
• Monitor for signs of sedation, nausea, or dizziness and provide interventions, such as antiemetics, as prescribed.
• Educate the client and family on the safe use of opioids, including proper dosing and the importance of tapering if opioids are required for longer periods.

✘Incorrect answer options:

Ensure the client does not develop addiction. Preventing addiction is an important consideration but not the primary goal in the short-term use of opioids for postoperative pain. Addiction is rare when opioids are used appropriately for acute pain under medical supervision.

Support the client’s ability to move around. While mobility is crucial for postoperative recovery, pain relief is the priority because untreated pain can hinder the client’s willingness and ability to move. Effective pain control facilitates movement rather than the other way around.

Minimize episodes of nausea. Nausea is a common side effect of opioids and should be addressed, but it is a secondary concern. Managing nausea does not replace the primary goal of relieving the client’s pain effectively.

EXPLANATION

✔Correct answer:

To prevent contamination of the surgical suture line. Following a laryngectomy, a nasogastric (NG) tube is placed primarily to protect the surgical suture line and facilitate healing by bypassing the normal swallowing mechanism. The surgical site, especially in the throat, is vulnerable to irritation or contamination from food, liquids, and gastric contents. Using an NG tube ensures that the client receives nutrition without risking damage or infection to the surgical area. This method reduces the risk of saliva or food particles contaminating the suture line, which could delay healing or lead to complications such as infection or fistula formation.

A laryngectomy involves removing the larynx and rerouting the airway. The surgery significantly alters normal anatomy, requiring careful management to prevent complications. An NG tube provides a temporary solution for nutrition and medication administration while the surgical site heals and swallowing is re-assessed.

Think of the surgical site as a freshly paved road under construction. The NG tube acts like a detour route, keeping cars (food and fluids) off the new pavement to ensure it sets properly without damage or contamination.

The nurse's role is to monitor the NG tube and ensure its proper functioning while providing education to the client and family.

• Explain that the NG tube is temporary and used to promote healing and prevent complications.
• Monitor for signs of infection or irritation around the surgical site, such as redness, swelling, or drainage.
• Ensure that the NG tube is properly secured and functioning, preventing accidental dislodgement.
• Flush the NG tube as prescribed to maintain patency and prevent blockages.
• Provide emotional support to the client and family, addressing concerns about temporary loss of oral intake and speech changes post-laryngectomy.

✘Incorrect answer options:

To reduce swelling and prevent difficulty swallowing. While swelling can occur post-operatively, the NG tube is not specifically placed to reduce swelling or prevent difficulty swallowing. Its purpose is more directly related to protecting the suture line and delivering nutrition.

To relieve stomach distention using suction. NG tubes can be used for gastric decompression in cases of bowel obstruction or distention, but in this case, the primary reason is to protect the surgical site. The NG tube in a laryngectomy client is typically not attached to suction but used for feeding.

To support the healing process of the oral mucosa. The NG tube is not directly involved in healing the oral mucosa. Its primary role is to bypass the surgical site and prevent contamination of the throat suture line. Oral mucosa healing is not the focus here.

EXPLANATION

✔Correct answer:

Raw fruits and vegetables. Clients with HIV who are experiencing diarrhea should avoid raw fruits and vegetables because they can be difficult to digest and may worsen gastrointestinal symptoms. Raw produce often contains insoluble fiber, which can irritate the gastrointestinal tract, leading to increased stool frequency and exacerbating diarrhea. Additionally, raw fruits and vegetables may harbor harmful bacteria or pathogens, which pose an increased risk of infection for immunocompromised clients like those with HIV. Cooking vegetables and peeling fruits can make them easier to digest and safer to consume.

Diarrhea is a common symptom in clients with HIV due to the virus itself, opportunistic infections, or medication side effects (e.g., antiretrovirals). Managing diarrhea through dietary modifications is essential to improving comfort, hydration, and nutrient absorption.

Eating raw fruits and vegetables during diarrhea is like putting rough gravel into a clogged pipe—it can worsen irritation and make things harder to manage. Cooked, softer options are like smoother materials that the pipe can handle more easily.

In addition to advising clients to avoid raw fruits and vegetables, Nurse Sarah should offer other dietary tips to manage diarrhea effectively:

• Encourage consumption of low-fiber, easily digestible foods like bananas, rice, applesauce, and toast (BRAT diet).
• Advise against spicy, greasy, or fried foods, as they can further irritate the gastrointestinal tract.
• Recommend drinking plenty of fluids (e.g., water, oral rehydration solutions) to prevent dehydration, but avoid caffeine and alcohol, which can worsen diarrhea.
• Suggest cooking or steaming vegetables to improve digestibility and reduce the risk of bacterial contamination.
• Encourage small, frequent meals to minimize stress on the gastrointestinal system.

✘Incorrect answer options:

Foods that are rich in calcium. Calcium-containing foods, such as dairy, are not universally contraindicated for diarrhea. While some clients with lactose intolerance may need to avoid dairy, others can tolerate lactose-free options or consume small amounts of yogurt with probiotics, which can be beneficial for gut health.

Canned or frozen vegetables. Canned or frozen vegetables, when cooked, are safe and often easier to digest than raw vegetables. They do not typically exacerbate diarrhea and are a good alternative to raw produce.

Processed meats. While processed meats (e.g., sausages, hot dogs) are not the healthiest option, they are not a primary cause of worsening diarrhea. However, clients should still limit high-fat processed meats to avoid additional gastrointestinal distress.

EXPLANATION

✔Correct answer:

A peanut butter and banana smoothie. A peanut butter and banana smoothie is the most appropriate snack for a client in the manic phase of bipolar disorder. During manic episodes, clients often exhibit increased energy levels, poor attention span, and difficulty sitting still. This can result in inadequate nutritional intake because they may be too restless to focus on eating a complete meal. A smoothie is an excellent choice because it is quick to consume, nutrient-dense, and provides a balance of macronutrients (carbohydrates, protein, and healthy fats).

• Peanut butter offers protein and healthy fats that support sustained energy.
• Bananas provide quick energy through natural sugars and potassium to support muscle and nerve function.
• The liquid consistency makes it easy to consume on the go, even if the client is unable to sit still.

This snack aligns with the goal of ensuring adequate caloric and nutritional intake while accommodating the client's behaviors during the manic phase.

Imagine trying to feed a child who can’t sit still because they’re bursting with energy. Giving them a healthy, drinkable option like a smoothie is like giving them fuel in a form they can easily handle, no matter where they are or how much they’re moving.

For clients in the manic phase, nurses must prioritize strategies to ensure proper nutrition and hydration, while recognizing that the client's hyperactive and distractible behaviors may interfere with regular eating.

• Provide nutrient-dense snacks that are easy to consume and require minimal effort to eat, such as smoothies, protein bars, or finger foods.
• Offer small, frequent snacks throughout the day rather than large meals to account for their difficulty sitting still.
• Encourage hydration by providing water or other fluids alongside snacks.
• Monitor for signs of weight loss or malnutrition due to decreased focus on food intake during the manic phase.
• Document the client’s food and fluid intake to ensure nutritional needs are being met.

✘Incorrect answer options:

Grilled chicken with steamed vegetables. While nutritious, this option is less suitable because it requires the client to sit down and eat with utensils. A manic client may struggle to sit still long enough to consume this meal, making it an impractical choice.

A bowl of soup with crackers. Soup is not ideal for a manic client because it can be messy and requires time and focus to eat, which may not align with the client's hyperactive state. Additionally, crackers may crumble and add to the mess, further frustrating the process.

A garden salad with dressing on the side. A salad is not the best option because it requires the client to sit still, use utensils, and focus on eating, which may be too challenging in the manic phase. Additionally, salads are often low in calories and may not provide enough energy for someone with heightened activity levels.

EXPLANATION

✔Correct answer:

15-30 minutes before sun exposure. Chemical sunscreens need time to properly bind to the skin and activate in order to provide effective protection from ultraviolet (UV) radiation. Most chemical sunscreens contain active ingredients such as avobenzone, oxybenzone, or octisalate, which absorb UV radiation and convert it into heat, preventing the skin from being damaged. By applying the sunscreen 15-30 minutes before exposure, it ensures the skin is adequately prepared for UV protection when the child is exposed to sunlight.

The 15-30 minute timeframe allows the sunscreen to create a uniform protective layer over the skin. Applying it immediately before exposure may leave the skin vulnerable while waiting for the sunscreen to be fully absorbed and activated.

Think of applying chemical sunscreen like setting up an umbrella at the beach. If you set up the umbrella before the sun gets too strong, you’ll already be shielded when it’s needed. Waiting until the sun is blazing might leave you exposed and at risk for sunburn while you scramble to set it up.

To ensure the effective use of sunscreen and protect children from harmful UV rays, the following practices should be considered:

• Educate caregivers and children on the proper application time for chemical sunscreens to ensure maximum effectiveness.
• Advocate for reapplication of sunscreen every 2 hours, or immediately after swimming or excessive sweating, as water and sweat can reduce its effectiveness.
• Encourage the use of additional protective measures, such as wide-brimmed hats, sunglasses, and UV-protective clothing.
• Choose a broad-spectrum sunscreen with SPF 30 or higher to protect against both UVA and UVB rays.
• Monitor for any signs of allergic reactions or irritation, particularly in children with sensitive skin.

✘Incorrect answer options:

Immediately before entering the water. Applying sunscreen immediately before entering the water does not give enough time for the sunscreen to activate or bind effectively to the skin. This timing leaves the skin vulnerable to UV damage during initial sun exposure.

Right after getting out of the water. While reapplying sunscreen after swimming is essential to maintain protection, this is not the appropriate time for the initial application. Sunscreen must already be applied and activated prior to sun exposure.

As soon as the child feels their skin getting warm. This approach is reactive and inadequate, as UV damage begins before the sensation of warmth occurs. Preventative measures like applying sunscreen ahead of time are more effective in protecting the skin.

EXPLANATION

✔Correct answer:

Preventing skin infections. Atopic dermatitis (also known as eczema) is a chronic skin condition characterized by intense itching, dryness, redness, and inflammation. In infants like Noah, the scratching caused by itching can lead to skin breakdown, increasing the risk of secondary bacterial infections, such as impetigo, caused by Staphylococcus aureus or Streptococcus pyogenes. Therefore, the primary nursing focus is to prevent skin infections by maintaining the integrity of the skin and minimizing scratching.

Interventions include keeping the skin well-moisturized to reduce dryness and cracking, using antihistamines or prescribed topical corticosteroids to control itching and inflammation, and trimming the infant's fingernails or using mittens to reduce the risk of injury from scratching. Ensuring the infant's environment is free from potential irritants, such as harsh detergents, fragrances, or rough fabrics, is also essential.

Think of the skin like a fortress wall protecting the body. In atopic dermatitis, the wall becomes cracked and weak. Preventing infections is like patching up the cracks and keeping invaders (bacteria) out while making sure the wall doesn't get further damaged.

To effectively manage atopic dermatitis in infants and prevent complications such as infections, Nurse Emily should focus on the following interventions:

• Apply an emollient (moisturizer) frequently, especially after bathing, to lock in moisture and repair the skin barrier.
• Avoid using harsh soaps, detergents, or scented products that can irritate the skin.
• Administer prescribed medications such as corticosteroid creams or antihistamines to manage inflammation and itching.
• Trim the infant’s nails and use soft cotton mittens to prevent injury from scratching.
• Teach parents to recognize early signs of infection, such as increased redness, swelling, warmth, or oozing, and seek medical attention promptly.

✘Incorrect answer options:

Administering medications to reduce fever. Fever is not typically associated with atopic dermatitis unless a secondary infection develops. The primary focus is on managing the skin condition and preventing infection, not treating fever.

Ensuring the skin remains completely dry. While it is important to avoid excessive moisture in skin folds that can lead to maceration, keeping the skin completely dry can worsen atopic dermatitis by increasing dryness and compromising the skin barrier. Moisturizing the skin is a key intervention.

Reducing the infant's oral fluid intake. Reducing fluid intake is not appropriate for managing atopic dermatitis. Adequate hydration supports overall skin health and helps maintain the skin's moisture levels. Limiting fluids would have no therapeutic benefit for this condition and could lead to dehydration.

EXPLANATION

✔Correct answer:

Avoid applying soap or lotion to the marked area during treatment. During radiation therapy, the blue ink markings on the skin indicate the precise area for radiation delivery and must remain intact to ensure accurate treatment. Applying soap, lotion, or other substances to the marked area can smudge, fade, or remove the markings, potentially leading to improper radiation targeting and compromised treatment outcomes. In addition, soap or lotion may irritate the already sensitive and irradiated skin, exacerbating side effects like erythema or desquamation.

The skin in the radiation field is highly sensitive and prone to irritation, dryness, and breakdown. Nurses should advise patients to follow specific skin care instructions, such as avoiding harsh chemicals, using only lukewarm water, and patting the skin dry without rubbing.

Imagine the ink markings on the skin as precise "coordinates" drawn on a treasure map leading to the treasure (the cancerous area). If the markings are smudged, washed away, or covered with extra layers like lotion or powder, the map becomes unclear, and the search party (radiation team) may miss the target entirely. By keeping the map clean and intact, the team can follow the exact path to deliver the treatment effectively.

Providing education about proper skin care during radiation therapy is a critical nursing role. Nurses must ensure the patient understands how to protect the radiation site and minimize skin irritation.

• Instruct the patient to clean the area gently with lukewarm water and avoid scrubbing or rubbing the skin.
• Advise against the use of soaps, lotions, deodorants, or powders unless approved by the healthcare team.
• Emphasize the importance of not removing or altering the ink markings until the physician or radiation therapist approves it.
• Encourage the patient to wear loose, soft clothing to reduce friction over the radiation site.
• Monitor the skin for signs of radiation dermatitis, such as redness, blistering, or peeling, and report severe reactions to the physician.

✘Incorrect answer options:

Clean off the markings with acetone or alcohol to prevent irritation. This is incorrect because the markings are essential for guiding radiation treatment and must not be removed. Acetone or alcohol could also cause significant skin irritation, especially on the already sensitive irradiated skin.

Apply a loose gauze dressing over the radiation site for protection. Covering the site with gauze is unnecessary and may trap moisture, irritate the skin, or disrupt the markings. The site is best left uncovered and exposed to air to promote skin integrity.

Use baby powder on the area to reduce moisture and irritation. Baby powder should not be used on irradiated skin, as it may contain ingredients that can irritate or damage the skin further. Powders can also form a residue that interferes with the ink markings or skin integrity.

EXPLANATION

✔Correct answer:

Clean the skin with water and gently pat it dry. Prior to hyperbaric oxygen therapy (HBOT), the skin should be cleaned with water and gently patted dry to ensure that the treatment area is free of debris, moisture, and any potential contaminants. This is important because HBOT delivers 100% oxygen at high pressure to promote wound healing, and any oils, lotions, or flammable materials on the skin (e.g., petroleum products) can pose a serious fire hazard in the hyperbaric chamber. Ensuring the skin is clean and dry also optimizes oxygen absorption at the tissue level and reduces the risk of infection or irritation during the procedure.

Hyperbaric oxygen therapy increases oxygen delivery to ischemic tissues, enhances angiogenesis (formation of new blood vessels), and improves the ability of white blood cells to fight infection. It is particularly effective for deep, chronic wounds like decubitus ulcers that are resistant to healing due to poor circulation.

Think of HBOT as a "breath of fresh air" for the wound. To maximize its healing effect, you need to start with a clean surface, just like you would clean a dusty window before opening it to let sunlight in.

Safety precautions are critical when preparing a client for hyperbaric oxygen therapy due to the risk of fire and the pressurized environment.

• Ensure the skin is clean and free of any lotions, oils, or flammable substances to prevent safety risks in the hyperbaric chamber.
• Assess the wound for signs of infection and ensure appropriate wound care measures are in place.
• Remove any jewelry, hearing aids, or metallic objects from the client to prevent burns or other hazards in the pressurized environment.
• Educate the client about the procedure, including the importance of avoiding makeup, hairspray, or nail polish before therapy.
• Verify that no contraindicated medications (e.g., certain chemotherapeutic agents) are being taken, as these may interact with HBOT.

✘Incorrect answer options:

Apply a lanolin-based lotion to moisturize the skin. Applying lotion is unsafe before HBOT, as many lotions contain oils that are flammable and pose a fire risk in the oxygen-rich environment of the hyperbaric chamber.

Cover the ulcer with petroleum gauze. Petroleum-based products are contraindicated in HBOT due to their flammable nature. Using them could endanger the client during the procedure.

Use an occlusive dressing over the wound site. Occlusive dressings may prevent proper oxygen exposure to the wound, reducing the effectiveness of the therapy. Wounds should typically remain open to benefit fully from the hyperbaric oxygen environment.

EXPLANATION

✔Correct answer:

Synergistic effect. When Demerol (meperidine), an opioid analgesic, is combined with Phenergan (promethazine), an antiemetic and antihistamine, the two medications work together to enhance each other’s effects. This is known as a synergistic effect, where the combined action of two drugs produces a greater effect than the sum of their individual effects. In this scenario, meperidine provides pain relief, while promethazine enhances sedation, reduces nausea (a common side effect of opioids), and potentiates the analgesic effect of meperidine.

This combination is particularly useful in postoperative settings because it helps manage pain effectively while minimizing nausea and vomiting, which can be distressing for the patient and hinder recovery.

Imagine taking a flashlight (meperidine) and a magnifying glass (promethazine). While the flashlight works well on its own, adding the magnifying glass makes the light beam stronger and more focused. Together, they achieve a better result than each would alone.

Nurses administering this combination should closely monitor the patient for side effects, as the synergistic effect can also amplify undesirable effects like excessive sedation or respiratory depression.

• Monitor the patient’s level of consciousness and respiratory status frequently, as both medications can depress the central nervous system (CNS).
• Assess pain relief and nausea control to determine the efficacy of the medication combination.
• Educate the patient on potential side effects, such as drowsiness or dizziness, and ensure safety precautions are in place to prevent falls.
• Administer the medications deep into a large muscle to minimize irritation and maximize absorption.
• Be vigilant for signs of opioid-induced respiratory depression or excessive sedation, particularly in elderly or opioid-naive patients.

✘Incorrect answer options:

Agonist effect. An agonist effect refers to a drug that activates a receptor to produce a physiological response. While meperidine acts as an agonist at opioid receptors, promethazine does not directly interact with opioid receptors, so this is not the correct explanation for their combined effect.

Antagonist effect. An antagonist effect occurs when one drug blocks or reduces the effect of another. In this case, promethazine does not counteract or inhibit the action of meperidine, so this option is incorrect.

Excitatory effect. This option is incorrect because the combination of meperidine and promethazine results in sedation and CNS depression rather than excitation. Both drugs have calming effects on the body when used together.

EXPLANATION

✔Correct answer:

Increased thirst and frequent urination. Increased thirst and frequent urination (symptoms of polyuria and polydipsia) are concerning signs that may indicate nephrogenic diabetes insipidus (NDI), a known potential side effect of lithium carbonate therapy. Lithium can impair the kidney's ability to concentrate urine by reducing the sensitivity of the renal collecting ducts to antidiuretic hormone (ADH), resulting in excessive water loss. This is a critical issue because it can lead to dehydration, electrolyte imbalances, and kidney damage if not addressed promptly.

Lithium is sometimes used off-label to suppress thyroid hormone release in hyperthyroidism. While effective, its side effects must be closely monitored, particularly its impact on renal function and electrolyte balance.

Imagine the kidneys as a sponge designed to soak up water (retain fluids). Lithium, in this case, acts like a coating on the sponge that prevents it from absorbing water properly, causing excessive water to leak out (frequent urination) and the body to crave more water to compensate (increased thirst).

If the client reports increased thirst and frequent urination, immediate nursing assessment and intervention are necessary to prevent complications. Monitoring lithium levels, renal function, and fluid status are critical nursing responsibilities.

• Monitor for other symptoms of lithium toxicity, such as nausea, tremors, confusion, or seizures.
• Assess renal function through lab work, including serum creatinine, blood urea nitrogen (BUN), and urine-specific gravity.
• Instruct the client to maintain adequate hydration to prevent further renal impairment.
• Collaborate with the healthcare provider to evaluate the need for dose adjustment or medication discontinuation if nephrogenic diabetes insipidus is suspected.
• Educate the client on the importance of routine follow-up appointments to monitor lithium levels and detect side effects early.

✘Incorrect answer options:

Blurred vision. While blurred vision can be associated with certain medications, it is not a common or notable side effect of lithium carbonate. If present, it may indicate an unrelated condition, such as hypertension or hyperglycemia, but it is not directly linked to lithium use.

Noticeable weight gain over the past year. Weight gain may be associated with hypothyroidism rather than hyperthyroidism. Lithium is not directly linked to significant weight gain, although thyroid suppression from prolonged lithium use could theoretically lead to hypothyroidism and subsequent weight gain. However, this is not as urgent as the symptoms of nephrogenic diabetes insipidus.

Ringing in the ears. Tinnitus (ringing in the ears) is not a recognized side effect of lithium carbonate therapy. It may indicate an unrelated issue, such as ototoxicity from other medications or a vestibular problem, but it does not prompt concern about lithium's impact on renal function or fluid balance.

EXPLANATION

✔Correct answer:

It is part of a series of vaccines protecting against DPT and Hib. The Tetramune injection is a combination vaccine that provides protection against diphtheria, pertussis (whooping cough), tetanus (DPT), and Haemophilus influenzae type b (Hib). These are serious diseases that can cause significant morbidity and mortality in infants and young children. Administering this vaccine at 2 months of age is part of the recommended childhood immunization schedule to provide early immunity during a vulnerable period. It is given as a series of doses, typically at 2, 4, 6, and 12–15 months of age.

This vaccine stimulates the immune system to produce antibodies against the four diseases without causing the diseases themselves. The child will develop immunity through this controlled exposure, which reduces the risk of severe infections.

Imagine your immune system as a security team. The Tetramune vaccine acts like a training program where the security team learns to recognize four dangerous intruders (diphtheria, pertussis, tetanus, and Hib) and prepares to fight them off if they ever try to break in.

After administering vaccines, it is crucial to educate parents about the importance of completing the vaccination series and observing for potential side effects.

• Inform the mother about the normal side effects, such as mild fever, redness, or swelling at the injection site, and reassure her that these are common and temporary.
• Emphasize the importance of following the vaccination schedule to ensure full protection against these diseases.
• Provide written information about the vaccine and its benefits, as well as instructions on when to call the healthcare provider (e.g., if there are signs of a severe allergic reaction).
• Document the vaccine administration in the baby's medical record, including the date, site of injection, and vaccine lot number.
• Encourage the mother to ask questions and ensure that she feels confident about the care her baby is receiving.

✘Incorrect answer options:

This vaccine will need to be repeated when the child turns 4 years old. While booster doses of some vaccines are required at 4–6 years of age (e.g., DTaP and IPV), the primary series of the Tetramune vaccine is completed by 15 months. This statement confuses the timing of the vaccine series.

It is administered to check if the baby is susceptible to pertussis. The vaccine is not a diagnostic test to determine susceptibility. Instead, it actively immunizes the child against pertussis and the other diseases.

It is a one-time vaccine that protects against MMR and varicella. The Tetramune vaccine does not protect against measles, mumps, rubella (MMR), or varicella (chickenpox). Those vaccines are separate and administered later in the childhood immunization schedule (typically at 12–15 months of age).

EXPLANATION

✔Correct answer:

Monitor the client’s blood sugar levels. After a transsphenoidal hypophysectomy (surgical removal of the pituitary gland or tumor), monitoring blood sugar levels is a priority because the pituitary gland plays a key role in regulating hormones, including those that affect blood sugar, such as growth hormone and cortisol. Surgical manipulation of the pituitary can lead to hormonal imbalances, including adrenal insufficiency, which can cause hypoglycemia. Additionally, damage to the pituitary gland may result in diabetes insipidus or syndrome of inappropriate antidiuretic hormone secretion (SIADH), both of which can affect fluid and electrolyte balance. Monitoring blood sugar levels helps detect early signs of complications and ensures timely interventions.

Acromegaly is caused by excessive growth hormone secretion, often due to a pituitary adenoma. The hypophysectomy addresses the overproduction of growth hormone, but post-operatively, careful monitoring of endocrine function is essential due to the disruption of pituitary hormone regulation.

Think of the pituitary gland as the body's "control tower" that coordinates hormone signals. After surgery, the control tower is offline, and systems like blood sugar regulation may become unsteady. Monitoring blood sugar levels ensures that the body stays on track while adjusting to this major change.

Post-operative care after a transsphenoidal hypophysectomy involves monitoring for complications, ensuring adequate recovery, and preventing stress on the surgical site.

• Monitor neurological status frequently to detect early signs of increased intracranial pressure or cerebrospinal fluid (CSF) leaks.
• Assess for signs of diabetes insipidus (excessive thirst and urination) or SIADH (fluid retention and hyponatremia).
• Maintain the client in a high Fowler’s or semi-Fowler’s position to reduce intracranial pressure and promote drainage.
• Avoid activities that increase intracranial pressure, such as coughing, sneezing, or straining during bowel movements.
• Monitor for post-operative complications, such as CSF leakage, meningitis, or adrenal insufficiency.

✘Incorrect answer options:

Perform hourly suctioning of the mouth and pharynx. Suctioning should be avoided unless absolutely necessary because it can disrupt the surgical site and increase the risk of bleeding or CSF leakage. Post-operatively, the client’s airway is usually maintained without frequent suctioning.

Position the client in a low Trendelenburg position. Low Trendelenburg positioning (where the head is lower than the feet) is contraindicated because it increases intracranial pressure, which can compromise healing at the surgical site and increase the risk of complications like bleeding or CSF leakage.

Encourage the client to cough frequently. Frequent coughing should be avoided because it increases intracranial pressure, placing stress on the surgical site and increasing the risk of complications. Instead, the nurse should encourage deep breathing exercises to maintain airway clearance without straining.

EXPLANATION

✔Correct answer:

Introduce solid foods one at a time, spaced 4–7 days apart. When introducing solid foods to infants, it is important to introduce new foods one at a time and wait 4–7 days before adding another new food. This approach allows parents and caregivers to monitor the infant for potential food allergies or intolerances, such as rashes, diarrhea, or vomiting. Additionally, it helps to identify which specific food might cause an adverse reaction.

The introduction of solid foods typically begins around 4–6 months of age when the infant shows signs of readiness, such as good head control, sitting up with support, and loss of the extrusion reflex (the reflex that pushes food out of the mouth with the tongue). Single-grain cereals (e.g., rice or oatmeal) are usually introduced first, followed by pureed vegetables, fruits, and eventually meats.

Introducing solid foods one at a time is like trying on new pairs of shoes—if you try multiple pairs at once, it’s hard to tell which one fits well or causes discomfort. Similarly, by offering one food at a time, parents can easily pinpoint if something "doesn't fit," such as an allergy or intolerance, ensuring the infant's safety and comfort.

Educating new parents about introducing solid foods safely is essential for the infant’s health and development. Nurse Emma can provide the following guidelines:

• Teach parents to start solids when the infant shows readiness signs (e.g., sitting up with support, good head control).
• Emphasize offering one new food at a time, waiting 4–7 days before introducing another, to monitor for allergies or intolerances.
• Encourage starting with single-grain cereals fortified with iron, as they are easy to digest and nutritionally beneficial.
• Avoid mixing solid foods into bottles, as this can increase the risk of choking and prevent the infant from learning to eat from a spoon.
• Educate parents to avoid potential allergens initially (e.g., honey before 1 year, which can cause botulism) and choking hazards (e.g., whole nuts, grapes).

✘Incorrect answer options:

Wait until the extrusion reflex disappears, typically around 8–10 months, to introduce solids. The extrusion reflex generally disappears around 4–6 months, which is when infants are developmentally ready for solid foods. Waiting until 8–10 months may delay necessary exposure to a variety of foods and textures, which can impact oral motor development.

Mix solid foods into a bottle or infant feeder to simplify feeding. This practice is not recommended, as it increases the risk of choking and does not allow the infant to develop the skill of eating from a spoon, which is important for oral motor development.

Start with fruits and vegetables as the first solid foods. While fruits and vegetables are important in an infant’s diet, single-grain cereals fortified with iron are typically recommended as the first solid food because they are easy to digest and address the infant’s increased need for iron after 6 months of age.

EXPLANATION

✔Correct answer:

Discontinue the Zyprexa (olanzapine) and notify the healthcare provider immediately. Severe muscle rigidity and an elevated temperature in a client taking olanzapine (Zyprexa) indicate a medical emergency known as Neuroleptic Malignant Syndrome (NMS). NMS is a rare but potentially life-threatening reaction to antipsychotic medications. It is characterized by hyperthermia, muscle rigidity, autonomic dysfunction (e.g., tachycardia, labile blood pressure), and altered mental status. The priority action is to discontinue the antipsychotic immediately and notify the healthcare provider for further orders, as prompt intervention is essential to prevent complications such as rhabdomyolysis, kidney failure, or even death.

NMS requires aggressive treatment, including supportive measures (e.g., cooling, hydration), administration of muscle relaxants (e.g., dantrolene) or dopamine agonists (e.g., bromocriptine), and monitoring in a critical care setting if necessary. Early recognition and cessation of the causative medication are critical steps in managing this emergency.

Think of NMS as a car overheating because of a malfunctioning engine. The first step is to stop the car (discontinue the medication) to prevent further damage and call for help (notify the healthcare provider) to address the underlying problem.

Once the medication is stopped and the provider is notified, the nurse should implement the following interventions to stabilize the client:

• Monitor vital signs closely, especially temperature, heart rate, and blood pressure.
• Provide cooling measures, such as cooling blankets or ice packs, to address hyperthermia.
• Ensure adequate hydration through intravenous fluids to prevent complications such as dehydration or kidney failure.
• Administer medications as ordered, such as dantrolene to reduce muscle rigidity or bromocriptine to restore dopamine balance.
• Prepare the client for potential transfer to a higher level of care if needed, such as an intensive care unit (ICU).

✘Incorrect answer options:

Administer the prescribed antipyretic for the fever. While fever is a key symptom of NMS, treating it with antipyretics alone does not address the underlying cause. Fever in NMS is related to central dysregulation rather than infection or inflammation, so antipyretics are unlikely to be effective.

Encourage the client to increase fluid intake to prevent dehydration. While hydration is important in managing NMS, encouraging oral fluid intake is insufficient and does not address the urgency of the condition. IV hydration and other critical interventions are typically required.

Reassure the client and monitor for further symptoms. Simply reassuring and monitoring the client delays necessary treatment and puts the client at risk for worsening symptoms or life-threatening complications. Prompt action is essential in NMS.

EXPLANATION

✔Correct answer:

Hold the medication and notify the physician. Digoxin (Lanoxin) is a cardiac glycoside commonly used to treat heart failure and atrial fibrillation by improving the heart's contractility and slowing the heart rate. Before administering digoxin, the nurse must always check the patient’s apical pulse for one full minute. If the pulse is less than 60 beats per minute, as in this case, the medication should be held, and the prescribing physician should be notified.

A heart rate below 60 bpm is a potential sign of digoxin toxicity or an excessive response to the medication. Administering the drug under these circumstances could exacerbate bradycardia, leading to dangerous complications such as heart block or asystole.

Giving digoxin to a patient with a slow heart rate is like stepping on the brakes of a car that's already barely moving. It can bring the car (or the heart) to a complete stop, which is dangerous.

In addition to holding the medication and notifying the physician, nurses should assess the patient further and prepare to manage potential complications. Here are key nursing actions:

• Monitor for signs of digoxin toxicity, such as nausea, vomiting, confusion, visual disturbances (e.g., seeing halos or yellow-green vision), or worsening bradycardia.
• Recheck the apical pulse after 30 minutes to confirm findings and provide updated information to the physician.
• Review the patient's recent serum digoxin level if available. Therapeutic levels typically range from 0.5–2.0 ng/mL. Levels above this range may indicate toxicity.
• Assess potassium levels, as hypokalemia increases the risk of digoxin toxicity and may contribute to bradycardia.
• Follow the physician's orders regarding adjustments to the medication dosage or discontinuation.

✘Incorrect answer options:

Document the pulse rate and proceed with administering the medication. Administering digoxin despite a low heart rate puts the patient at risk for severe bradycardia or even cardiac arrest. Documentation is important, but action must be taken to prevent harm.

Administer the medication and continue monitoring the heart rate. This option is unsafe because the heart rate is already below the safe threshold (60 bpm) for digoxin administration. Waiting to "monitor" without intervention could lead to a life-threatening situation.

Delay the medication until the heart rate rises naturally. There is no guarantee the heart rate will increase on its own. Additionally, holding the medication without notifying the physician delays appropriate treatment and evaluation of the underlying cause of bradycardia.

EXPLANATION

✔Correct answer:

Signs of bleeding and pale skin. In acute leukemia, bone marrow function is impaired, leading to a reduction in the production of healthy red blood cells, white blood cells, and platelets. As a result, clients with acute leukemia are at a high risk of anemia (manifesting as pale skin and fatigue) and thrombocytopenia (low platelet count), which increases the risk of bleeding. Monitoring for signs of bleeding, such as petechiae, ecchymoses, or spontaneous bleeding from mucosal surfaces, is critical. Pale skin, a symptom of anemia, also indicates diminished oxygen-carrying capacity of the blood, which can result in fatigue and compromised organ perfusion. These complications can rapidly worsen, so they are a priority for monitoring.

Bleeding complications, particularly internal bleeding, pose an immediate threat to life, while anemia can lead to hypoxia and diminished energy levels in the client. Nurse Karen must carefully monitor Mia’s skin, mucosal surfaces, vital signs, and complete blood count (CBC) for indicators of worsening anemia and thrombocytopenia.

Think of the blood as a team of workers. Platelets are like construction workers that patch up leaks (bleeding), while red blood cells are delivery drivers that bring oxygen to the body's "factories." In leukemia, the team is severely understaffed, so leaks and shortages become a serious concern.

Nurse Karen should focus on implementing interventions to minimize the risk of bleeding and monitor for anemia-related symptoms:

• Regularly assess for bruising, petechiae, or prolonged bleeding from minor injuries.
• Monitor hemoglobin, hematocrit, and platelet levels as part of the client’s CBC.
• Check vital signs, especially heart rate and blood pressure, for indications of blood loss or hypoxia.
• Educate parents about avoiding activities or toys that could cause injury (e.g., sharp objects or rough play).
• Administer blood or platelet transfusions as ordered to address severe anemia or thrombocytopenia.

✘Incorrect answer options:

Abdominal pain and loss of appetite. While abdominal pain and loss of appetite may occur due to organ involvement (e.g., splenomegaly or hepatomegaly) or chemotherapy side effects, these symptoms are less life-threatening than bleeding or anemia and are not the highest priority.

Fatigue and the appearance of bruises. Fatigue and bruising are common symptoms of anemia and thrombocytopenia in leukemia, but these are secondary to the more serious issues of bleeding and pallor, which require immediate attention.

Petechiae and ulcers on mucosal surfaces. While petechiae are an important indicator of thrombocytopenia, ulcers on mucosal surfaces are more likely related to infection or mucositis, a side effect of treatment, and are not the primary concern in acute leukemia. Bleeding and anemia remain higher priorities.

EXPLANATION

✔Correct answer:

At the first bite of a meal. Precose (acarbose) is an alpha-glucosidase inhibitor that works by slowing the digestion and absorption of carbohydrates in the small intestine. This action helps to prevent postprandial (after-meal) hyperglycemia by delaying the release of glucose into the bloodstream. For maximum effectiveness, acarbose must be taken at the first bite of a meal so that it can immediately begin to inhibit the enzymes responsible for carbohydrate breakdown. Taking it after the meal or at other times would reduce its effectiveness in controlling blood sugar spikes.

Acarbose inhibits the enzyme alpha-glucosidase, which breaks down complex carbohydrates into glucose in the small intestine. By blocking this process, it reduces the rate of glucose absorption and helps control blood sugar levels after eating.

Imagine acarbose as a "speed bump" on a road filled with cars (carbohydrates). To slow the cars down, the speed bump (acarbose) must be in place right as the traffic starts (the first bite of the meal). If you place the speed bump too late (after the meal), the cars have already passed, and the effect is lost.

Teaching clients how and when to take acarbose is crucial to its success in managing diabetes. Nurses should also educate clients about potential side effects and other important considerations.

• Instruct the client to take acarbose with the first bite of every meal, ensuring proper timing for blood sugar control.
• Explain that acarbose works on carbohydrate digestion, so it should not be taken if the meal contains no carbohydrates.
• Educate the client about common side effects, such as flatulence, diarrhea, and abdominal discomfort, which occur due to undigested carbohydrates fermenting in the colon.
• Advise the client to carry a glucose tablet or gel to treat hypoglycemia because acarbose delays the digestion of complex carbohydrates, so sucrose (table sugar) may not effectively raise blood sugar levels in an emergency.
• Monitor the client’s blood sugar levels regularly and assess for any signs of liver dysfunction, as acarbose may rarely cause elevated liver enzymes.

✘Incorrect answer options:

One hour prior to meals. Taking acarbose an hour before meals is ineffective because the medication needs to act on carbohydrates as they are being ingested. Taking it this early would not provide the intended benefit.

Thirty minutes after eating a meal. Taking acarbose after eating significantly reduces its effectiveness because it cannot delay the absorption of carbohydrates that have already been digested and absorbed.

Once daily at bedtime. Acarbose is not effective when taken at bedtime because it works specifically during meals to reduce postprandial blood sugar spikes. Taking it once daily does not align with its intended use.

EXPLANATION

✔Correct answer:

Speaking and writing. Expressive aphasia, also known as Broca's aphasia, is a communication disorder caused by damage to the Broca's area in the frontal lobe of the brain, often as a result of a stroke. This condition primarily affects a person's ability to speak and write. Clients with expressive aphasia typically understand spoken language relatively well but have difficulty expressing themselves verbally or in writing. Speech may be slow, labored, and limited to short phrases or single words. Writing is similarly affected, with errors in spelling, grammar, and word selection.

Strokes that affect the left hemisphere of the brain, particularly the frontal lobe, can lead to expressive aphasia. While comprehension is preserved, the client struggles to produce language, which can be frustrating and emotionally taxing for both the client and caregivers.

Imagine the brain as a keyboard. In expressive aphasia, the keyboard is intact, but certain keys (used to produce speech or writing) are stuck or broken, making it hard for the person to type (communicate), even though they can still read and understand what’s on the screen (comprehension).

Communication with clients who have expressive aphasia requires patience, understanding, and adaptive strategies to support their ability to express themselves.

• Encourage the use of alternative forms of communication, such as gestures, picture boards, or communication apps.
• Give the client adequate time to speak without interrupting or finishing their sentences for them.
• Use simple, short phrases and yes/no questions to facilitate communication.
• Reassure the client and their family that expressive aphasia does not impact intelligence or cognitive comprehension.
• Collaborate with speech therapists to implement language recovery techniques tailored to the client's needs.

✘Incorrect answer options:

Understanding spoken language. Difficulty understanding spoken language is characteristic of receptive aphasia (Wernicke's aphasia), not expressive aphasia. Clients with expressive aphasia typically comprehend language but struggle to produce it.

Performing purposeful motor actions. Difficulty performing purposeful motor actions is called apraxia, which can occur with strokes but is unrelated to expressive aphasia. Apraxia involves motor planning deficits, not language production.

Identifying and using objects appropriately. The inability to identify or use objects appropriately is called agnosia, which is a perceptual deficit. It does not describe the language difficulties seen in expressive aphasia.

EXPLANATION

✔Correct answer:

Eating a meal. Clients with duodenal ulcers often report that eating a meal relieves their abdominal discomfort. This is because food in the stomach acts as a buffer, temporarily neutralizing stomach acid and reducing irritation of the ulcerated area in the duodenum. Pain from a duodenal ulcer typically occurs 2–5 hours after eating, when the stomach is empty, or during the night when acid production continues without the buffering effect of food. This is in contrast to gastric ulcers, where eating may worsen pain due to increased acid production during digestion.

Duodenal ulcers are a form of peptic ulcer disease caused by an imbalance between protective mechanisms of the gastrointestinal mucosa and damaging factors, such as excess gastric acid or infection with Helicobacter pylori. The duodenum lacks the robust protective mucus lining found in the stomach, making it more susceptible to acid damage. Food temporarily relieves symptoms by diluting acid and coating the ulcer.

Imagine pouring acid onto a surface—it causes damage (pain). Adding water (food) dilutes the acid, temporarily soothing the surface (reducing pain).

Nurse Carla should assess Mr. Davis's symptoms thoroughly and educate him about lifestyle changes and treatments to manage his condition.

• Ask the client about the timing, duration, and characteristics of pain, as well as any foods or actions that exacerbate or relieve it.
• Educate the client about avoiding irritants like alcohol, caffeine, and NSAIDs, which can worsen symptoms by increasing gastric acid secretion.
• Encourage small, frequent meals to prevent long periods of fasting that exacerbate acid-related discomfort.
• Reinforce the importance of adhering to prescribed treatments, such as proton pump inhibitors (PPIs) or H2 receptor blockers, to reduce acid production.
• Provide information about testing and treatment for H. pylori if it is confirmed as a contributing factor.

✘Incorrect answer options:

Skipping a meal: Skipping meals worsens symptoms for clients with duodenal ulcers. Long periods without food allow gastric acid to accumulate, irritating the duodenal lining and causing pain.

Lying down in a recumbent position: Lying down may not relieve pain associated with duodenal ulcers. In fact, for clients with concurrent gastroesophageal reflux disease (GERD), this position may exacerbate discomfort by allowing acid to flow back into the esophagus.

Sitting upright after eating: Sitting upright is more commonly recommended for GERD management to prevent acid reflux. While it may provide mild relief, it does not address the root cause of duodenal ulcer pain, which is alleviated by eating.

EXPLANATION

✔Correct answer:

Stool resembling "currant jelly." Currant jelly stool is a classic finding in intussusception, a condition where one segment of the intestine telescopes into another, causing obstruction. This symptom results from a mixture of blood and mucus in the stool, which appears dark red and gelatinous, resembling currant jelly. This occurs due to irritation and compromised blood flow in the intestinal walls, leading to bleeding and mucus production.

Intussusception commonly affects children under the age of 2 and is the most frequent cause of intestinal obstruction in this age group. The telescoping of the bowel causes venous and lymphatic congestion, leading to bowel ischemia, bleeding, and the characteristic stool appearance. Other signs and symptoms include sudden onset of severe abdominal pain, episodes of crying and pulling the legs to the abdomen (indicative of cramping), and a palpable sausage-shaped mass in the right upper quadrant or mid-abdomen.

Imagine the intestine as a long telescope that collapses into itself. This "telescoping" traps blood and mucus, like a blocked hose collecting debris, leading to the signature currant jelly stool when the trapped material is expelled.

Intussusception is a medical emergency that requires prompt recognition and treatment to prevent serious complications, such as bowel perforation or necrosis. The nurse plays a critical role in monitoring symptoms, preparing the child for diagnostic tests, and educating the family.

• Assess for signs of bowel obstruction, including currant jelly stool, abdominal distension, and pain.
• Monitor the child for episodes of sudden crying and lethargy, which may indicate ongoing intussusception or ischemia.
• Prepare the child and family for diagnostic tests, such as an abdominal ultrasound, which can confirm the telescoping bowel segments.
• Collaborate with the healthcare team to prepare for treatment, such as a therapeutic enema (air or barium enema), which is both diagnostic and therapeutic in many cases.
• Monitor for signs of perforation, such as fever, increased abdominal distension, or peritonitis, and alert the provider immediately if these occur.

✘Incorrect answer options:

Episodes of projectile vomiting. While vomiting may occur in intussusception due to bowel obstruction, projectile vomiting is more commonly associated with pyloric stenosis, a condition where the pylorus muscle thickens, causing obstruction of food from the stomach to the small intestine.

Stool that appears "ribbon-like." Ribbon-like stool is characteristic of conditions like Hirschsprung's disease, where there is a lack of nerve cells in part of the colon, causing chronic constipation and narrow stools. This finding is not associated with intussusception.

A palpable mass located over the flank area. A palpable mass in intussusception is typically felt in the right upper quadrant or mid-abdomen, described as a sausage-shaped mass. A flank-area mass is more suggestive of renal or adrenal conditions, not intussusception.

EXPLANATION

✔Correct answer:

The head of the pancreas. The Whipple procedure (also called a pancreaticoduodenectomy) is a complex surgical procedure typically performed to treat pancreatic cancer located in the head of the pancreas. This region of the pancreas is closely associated with the common bile duct, duodenum, and other structures. Tumors in the head of the pancreas often cause symptoms such as jaundice (due to bile duct obstruction), weight loss, and abdominal pain, making early diagnosis and surgical intervention more likely.

During the Whipple procedure, the surgeon removes the head of the pancreas, part of the duodenum, the gallbladder, and a portion of the bile duct. The remaining portions are reconnected to preserve digestive and biliary function. This surgery is most commonly performed for cancers in the pancreatic head because of the anatomical relationships and the higher likelihood of obstructive symptoms in this location.

Imagine the pancreas as a tree, with the head being the base where the roots (ducts) are located. When there's a problem (like cancer) in the base, it affects the roots (ducts) connected to it. The Whipple procedure is like carefully cutting away the diseased base while preserving as much of the tree as possible.

Nurse Sandra should focus on preparing Mr. Caldwell both physically and emotionally for this major surgery and the recovery process:

• Educate the client about the procedure, including its purpose and the anatomy involved (e.g., removal of the pancreatic head, duodenum, etc.).
• Monitor for signs of malnutrition and weight loss preoperatively, as pancreatic cancer and digestive enzyme insufficiency often cause these issues.
• Prepare the client for possible postoperative changes, such as altered digestion or the need for pancreatic enzyme replacement therapy.
• Reinforce the importance of postoperative follow-ups and monitoring for complications such as delayed gastric emptying, fistulas, or infection.
• Provide emotional support and address any concerns about the risks or recovery from this extensive procedure.

✘Incorrect answer options:

The tail of the pancreas. The Whipple procedure is not typically performed for cancers in the tail of the pancreas. Instead, distal pancreatectomy, which involves removing the tail and sometimes the body of the pancreas, is the preferred surgical approach.

The body of the pancreas. While the Whipple procedure may occasionally involve part of the body of the pancreas, it is primarily indicated for cancers in the pancreatic head. Tumors in the body of the pancreas are less likely to cause obstructive symptoms and are managed differently.

The entire pancreas. The Whipple procedure does not remove the entire pancreas. Total pancreatectomy, which involves removing the entire pancreas, is a separate and more extensive procedure that may be performed for widespread pancreatic disease or multifocal tumors.

EXPLANATION

✔Correct answer:

Whole-grain cereal. Whole-grain cereal is high in fiber, and while fiber is generally recommended for clients with diverticulosis to prevent flare-ups, it is not advised during an acute episode of diverticulitis. During an acute flare-up, the inflamed diverticula can become irritated by fiber-rich or rough foods, worsening abdominal pain, diarrhea, and inflammation. Instead, a low-residue or low-fiber diet is typically recommended during acute diverticulitis to allow the bowel to rest and reduce irritation.

Once symptoms resolve, the client can gradually reintroduce fiber into the diet to help maintain regular bowel movements and prevent future episodes. Whole-grain cereals, being high in insoluble fiber, are more suitable during remission and not during active inflammation.

Think of the digestive tract during diverticulitis as a scraped knee. Adding fiber-rich foods (like whole-grain cereal) during a flare-up is like rubbing a rough cloth over the scrape—it only makes things worse. A softer, gentler approach (low-fiber foods) helps it heal.

Nurse Laura should educate Mr. Thompson on appropriate dietary modifications during an acute flare-up and support symptom management:

• Encourage a low-fiber or clear-liquid diet during acute inflammation to allow bowel rest (e.g., white rice, cooked or canned fruits without skins, white bread).
• Avoid foods that are high in fiber, seeds, or roughage (e.g., whole-grain cereals, nuts, popcorn, raw vegetables).
• Promote hydration with adequate fluids to prevent dehydration, especially if diarrhea is present.
• Teach the client to gradually reintroduce high-fiber foods, such as whole grains, fruits, and vegetables, once symptoms resolve and inflammation subsides.
• Monitor for signs of complications, such as abscess formation, perforation, or peritonitis (e.g., severe abdominal pain, rigid abdomen, or fever).

✘Incorrect answer options:

Mashed potatoes. Mashed potatoes are low in fiber and generally well-tolerated during a diverticulitis flare-up. They do not aggravate inflamed diverticula and are part of a low-residue diet.

Steamed carrots. Steamed carrots are soft and low in fiber when cooked, making them suitable during a diverticulitis flare-up. Unlike raw vegetables, cooked vegetables are gentler on the digestive tract.

Baked fish. Baked fish is a protein-rich, low-residue food that is unlikely to irritate the digestive system during diverticulitis. It is a safe dietary option during an acute episode.

EXPLANATION

✔Correct answer:

Grilled chicken with quinoa and steamed broccoli. This meal is the most appropriate for a client with celiac disease because it is entirely free of gluten. Celiac disease is an autoimmune disorder in which ingestion of gluten—a protein found in wheat, rye, and barley—triggers an immune response that damages the small intestine, leading to malabsorption of nutrients and other gastrointestinal symptoms. Foods like grilled chicken, quinoa, and steamed broccoli are naturally gluten-free and safe for consumption.

Quinoa is a gluten-free grain substitute that provides fiber, protein, and essential nutrients. Broccoli adds vitamins (like vitamin C and K), while grilled chicken is an excellent source of lean protein, making this meal both balanced and safe.

Think of celiac disease like a strict "no entry" sign for gluten in the digestive system. If gluten sneaks in, it causes havoc, damaging the "roads" (intestinal lining). By choosing gluten-free options like quinoa and vegetables, you're ensuring a smooth path with no disruptions.

For clients with celiac disease, the nurse must provide dietary guidance and education on safe meal choices. Nurses should also emphasize the importance of avoiding hidden sources of gluten, which can sometimes be found in processed or packaged foods.

• Educate the client on naturally gluten-free foods, such as fruits, vegetables, lean meats, poultry, fish, and gluten-free grains like quinoa, rice, or corn.
• Advise the client to read food labels carefully to identify hidden sources of gluten, including additives like malt and modified food starch derived from wheat.
• Encourage clients to avoid cross-contamination by using separate cooking utensils and surfaces for gluten-free meals.
• Discuss the use of certified gluten-free products and highlight the importance of maintaining a strict gluten-free diet to prevent symptoms and long-term complications.
• Offer resources, such as referrals to a dietitian or gluten-free recipe guides, to support dietary adherence.

✘Incorrect answer options:

Spaghetti with garlic bread and a side salad. This option is inappropriate because traditional spaghetti and garlic bread both contain gluten, which would trigger symptoms in a client with celiac disease. Even if gluten-free pasta were used, care must be taken to avoid contamination with gluten-containing bread.

Turkey sandwich on whole wheat bread with an apple. While the turkey and apple are gluten-free, the whole wheat bread contains gluten, making this meal unsuitable for someone with celiac disease.

Fried chicken with mashed potatoes and gravy. This meal is not safe because fried chicken is typically coated in wheat flour, and the gravy often contains gluten as a thickening agent. Unless explicitly prepared as gluten-free, these items would likely trigger an immune response.

EXPLANATION

✔Correct answer:

Respiratory stridor. Respiratory stridor is an alarming finding that requires immediate intervention, as it indicates potential airway obstruction. After a tonsillectomy, swelling in the throat, excessive bleeding, or aspiration can compromise the airway. Stridor, characterized by a high-pitched sound during inhalation, suggests significant airway narrowing and is a medical emergency. Failure to address this complication can lead to respiratory distress or arrest.

Post-tonsillectomy, swelling in the throat or laryngeal area can compress the airway. Additionally, blood or mucus can obstruct the airway if not cleared. Stridor reflects turbulent airflow caused by this narrowing and requires immediate medical attention to secure the airway and prevent hypoxia.

Imagine trying to breathe through a straw that has a partial blockage. The wheezing sound (stridor) is your body struggling to force air through the narrowed passage.

Nurse Lisa should act quickly to ensure Ethan’s airway is maintained and alert the physician immediately.

• Assess the airway thoroughly and monitor oxygen saturation levels to detect hypoxia.
• Position the child in an upright position to facilitate breathing and reduce airway obstruction.
• Provide humidified oxygen if ordered, as it can help reduce swelling and ease breathing.
• Have emergency equipment readily available, including suctioning devices and intubation supplies, in case of further airway compromise.
• Notify the physician immediately for further evaluation and potential intervention, such as administering corticosteroids to reduce swelling or performing surgical interventions if needed.

✘Incorrect answer options:

Hesitation or refusal to swallow: Refusal to swallow is a common response to pain after a tonsillectomy. While this requires pain management and encouragement to hydrate, it is not an urgent complication unless it leads to dehydration or difficulty breathing.

Drooling with blood-tinged saliva: Blood-tinged saliva is an expected finding post-tonsillectomy, as minor oozing from the surgical site is normal. However, significant bright red bleeding should be reported immediately.

A low-grade axillary temperature of 99°F: A mild fever is common after surgery due to the body’s inflammatory response. This does not indicate a serious complication and can often be managed with antipyretics and hydration.

EXPLANATION

✔Correct answer:

A sore throat. Pulmozyme (dornase alfa) is an inhalation medication used in the treatment of cystic fibrosis to reduce mucus viscosity and improve airway clearance. By breaking down the DNA in thick mucus secretions, Pulmozyme helps decrease mucus accumulation in the lungs, thus reducing the risk of respiratory infections and improving breathing.

A common side effect of Pulmozyme is a sore throat, which occurs due to the irritation of the mucosal membranes during inhalation therapy. Other mild side effects may include hoarseness, rhinitis, and occasionally a mild cough. These side effects are typically transient and do not usually require discontinuation of the medication.

Using Pulmozyme is like using a detergent to break down grease in a sink. While it clears the blockage effectively, the strong action of the detergent might temporarily irritate your skin (or, in this case, the throat).

Nurse Lisa should monitor Ella for side effects and provide supportive care to ensure the therapy is effective and well-tolerated:

• Encourage Ella to drink plenty of fluids to soothe her throat and keep mucus thin.
• Ensure proper use of the nebulizer device to minimize irritation (e.g., ensure correct technique and cleaning of the device).
• Monitor for other side effects, such as hoarseness or coughing, and assess Ella’s ability to tolerate the medication.
• Educate Ella’s parents about the purpose of Pulmozyme and its potential side effects, emphasizing that a sore throat is generally mild and temporary.
• Advise parents to report severe or persistent side effects, such as difficulty breathing or worsening respiratory symptoms.

✘Incorrect answer options:

Increased weight gain. Pulmozyme does not directly affect weight. While weight gain is a goal in managing cystic fibrosis due to the disease’s impact on nutrition, it is typically achieved through nutritional interventions and pancreatic enzyme replacement therapy, not Pulmozyme.

Hair loss. Pulmozyme is not associated with hair loss. Hair loss is more commonly linked to systemic medications, chemotherapy, or nutritional deficiencies.

Brittle nails. Brittle nails can occur in cystic fibrosis due to malnutrition or vitamin deficiencies, but it is not a side effect of Pulmozyme. This issue would need to be addressed through nutritional management, not changes to inhalation therapy.