NCLEX- PN Practice Exam 5

EXPLANATION

✔Correct answer:

A brief lapse in consciousness. Petit mal seizures, now more commonly referred to as absence seizures, are characterized by a brief lapse in consciousness. These seizures typically last for a few seconds (often 5–10 seconds) and are more common in children. During an absence seizure, the client may appear to "blank out" or stare into space, seeming inattentive. Other subtle signs may include slight twitching of the facial muscles (e.g., eye blinking or lip smacking) or minimal changes in posture.

The child is usually unaware that the seizure has occurred, and there is no postictal confusion afterward. These episodes can occur multiple times a day and may significantly impact a child's ability to focus and learn in school, often being mistaken for daydreaming or inattentiveness.

Imagine a flickering lightbulb that briefly goes out for a few seconds but turns back on without damage. That brief "flicker" is like an absence seizure, where the brain briefly "disconnects" but quickly resumes normal function without obvious external effects.

Nurses should educate caregivers and teachers to recognize absence seizures and understand their impact on daily functioning.

• Observe for signs of brief lapses in consciousness and document the duration and frequency of episodes.
• Educate caregivers and teachers that absence seizures are not behavioral issues but are medical conditions requiring treatment.
• Encourage the child’s caregiver to monitor the child for triggers such as hyperventilation or flashing lights, which may precipitate seizures.
• Provide support for compliance with prescribed antiepileptic medications, such as ethosuximide or valproic acid, which are commonly used to treat absence seizures.
• Stress the importance of follow-up care, including EEGs, to confirm the diagnosis and monitor treatment efficacy.

✘Incorrect answer options:

Short, abrupt muscle contractions. This is incorrect because short, abrupt muscle contractions are characteristic of myoclonic seizures, not petit mal (absence) seizures. Myoclonic seizures involve sudden jerks of the arms, legs, or other muscle groups.

Quick, bilateral severe jerking movements. This is incorrect because quick, severe bilateral jerking movements are characteristic of tonic-clonic (grand mal) seizures, which involve both tonic (stiffening) and clonic (jerking) phases and are typically much more dramatic than absence seizures.

Sudden loss of muscle tone. This is incorrect because a sudden loss of muscle tone is characteristic of atonic seizures (also called "drop attacks"), which cause the client to suddenly go limp or fall, risking injury.

EXPLANATION

✔Correct answer:

Advise the student to avoid contact sports for 1–2 months. The most critical instruction for a student recovering from mononucleosis is to avoid contact sports for 1–2 months, or as directed by their healthcare provider. Mononucleosis, caused by the Epstein-Barr virus, often leads to splenomegaly (enlarged spleen), making the spleen more vulnerable to rupture. A ruptured spleen is a medical emergency that can result from trauma, such as an impact during contact sports.

Since splenic rupture is a potentially life-threatening complication, it is vital to ensure the student avoids activities where the abdomen could be subjected to trauma until the spleen has returned to its normal size. Clearance for resuming physical activities should always be obtained from the healthcare provider following imaging or clinical assessment.

Think of the spleen as a balloon that’s been overinflated (enlarged). Until it shrinks back to its normal size, even a small bump could cause it to pop, which would be dangerous. Avoiding contact sports gives it time to safely deflate.

When assisting students or clients recovering from mononucleosis, nurses should focus on promoting safety and gradual recovery while addressing lingering fatigue and other symptoms.

• Educate the student and family about the risks of splenic rupture and the importance of avoiding contact sports and heavy lifting until cleared by a healthcare provider.
• Encourage the student to pace their activities and allow time for rest, as fatigue is a common lingering symptom of mononucleosis.
• Advise the student to maintain proper hydration and a balanced diet to support recovery.
• Inform teachers and school staff about the student’s condition so that accommodations can be made if needed (e.g., a reduced workload).
• Monitor for any signs of complications, such as sudden abdominal pain, dizziness, or shoulder pain, which could indicate a ruptured spleen and require immediate medical attention.

✘Incorrect answer options:

Encourage the student to drink more fluids during the school day. While staying hydrated is beneficial for overall recovery, it is not the most critical instruction. Avoiding contact sports is a priority due to the risk of splenic rupture, which is far more urgent and specific to mononucleosis recovery.

Suggest having snacks twice a day to prevent low blood sugar. This is incorrect because mononucleosis does not typically affect blood sugar levels. While a healthy diet can support recovery, this instruction is not directly relevant to the condition.

Inform the student to continue antibiotic therapy for 6 months. This is incorrect because mononucleosis is caused by a virus (Epstein-Barr virus), and antibiotics are not used to treat viral infections. Any antibiotics prescribed during the illness would have been to manage secondary bacterial infections, if present, and would not be continued long-term.

EXPLANATION

✔Correct answer:

Coconut oil. Coconut oil should be avoided or minimized in a low-cholesterol diet because it is high in saturated fat, which can raise levels of low-density lipoprotein (LDL), commonly referred to as "bad cholesterol." Elevated LDL levels contribute to the development of atherosclerosis and increase the risk of cardiovascular disease. Unlike other plant-based oils that are rich in heart-healthy monounsaturated and polyunsaturated fats, coconut oil contains over 80% saturated fat, making it less suitable for individuals managing high cholesterol.

Although coconut oil has gained popularity for its potential health benefits in other contexts, such as antimicrobial properties, its high saturated fat content makes it an unfavorable choice for those focused on reducing cholesterol and improving cardiovascular health.

Think of coconut oil as a "solidifying" oil that clogs the body's "pipes" (arteries), while oils like olive or canola act more like lubricants that help keep the pipes clear and smooth.

Nurse Lisa should educate Mrs. Collins on healthy fats and cooking oils to help her make better dietary choices for cholesterol management:

• Encourage the use of oils rich in monounsaturated fats (e.g., olive oil, avocado oil) and polyunsaturated fats (e.g., canola oil, sunflower oil), which help lower LDL cholesterol and increase high-density lipoprotein (HDL), or "good cholesterol."
• Advise Mrs. Collins to limit saturated fats found in oils like coconut oil, butter, and palm oil, as well as animal-based products like fatty meats and full-fat dairy.
• Discuss portion control, as even heart-healthy oils are calorie-dense and should be used in moderation.
• Teach Mrs. Collins to incorporate other cholesterol-lowering foods into her diet, such as whole grains, nuts, seeds, fruits, vegetables, and fatty fish (e.g., salmon, mackerel).
• Recommend reading nutrition labels to identify hidden sources of saturated fats in processed or packaged foods.

✘Incorrect answer options:

Olive oil. Olive oil is a heart-healthy choice because it is high in monounsaturated fats, which help lower LDL cholesterol and reduce inflammation. It is a recommended oil for a low-cholesterol diet.

Canola oil. Canola oil is another healthy option, as it is low in saturated fat and contains both monounsaturated and polyunsaturated fats, which can help improve cholesterol levels. It is suitable for cooking and baking.

Avocado oil. Avocado oil is rich in monounsaturated fats and antioxidants, making it a good choice for a heart-healthy diet. Like olive and canola oils, it can help lower LDL cholesterol and improve overall cardiovascular health.

EXPLANATION

✔Correct answer:

Zyprexa (olanzapine). The Parkinsonian symptoms of tremors, rigidity, and bradykinesia (slowness of movement) that Nurse Elena observed in the client are most likely caused by Zyprexa (olanzapine), an atypical antipsychotic medication. Olanzapine, like other antipsychotics, blocks dopamine receptors (D2 receptors) in the brain. This dopamine blockade can result in extrapyramidal symptoms (EPS), which are movement disorders resembling Parkinson's disease. Drug-induced Parkinsonism is a common form of EPS and occurs when dopamine activity in the basal ganglia is reduced due to antipsychotic medication.

While atypical antipsychotics like olanzapine have a lower risk of EPS compared to older typical antipsychotics (e.g., haloperidol), they can still cause these symptoms, particularly at higher doses or in clients who are more sensitive to dopamine blockade.

Think of dopamine as oil for the brain’s motor system. Antipsychotics like olanzapine reduce dopamine, similar to draining oil from an engine. Without enough oil (dopamine), the motor system struggles, leading to jerky or stiff movements, like those seen in Parkinsonism.

Managing EPS involves monitoring for symptoms, adjusting medication regimens, or administering medications to counteract the effects.

• Monitor for early signs of EPS, including tremors, rigidity, bradykinesia, akathisia (restlessness), and dystonia (muscle spasms).
• Administer anticholinergic medications such as Cogentin (benztropine) or Benadryl (diphenhydramine), which can help relieve EPS by balancing dopamine and acetylcholine levels.
• Consult with the prescribing provider about adjusting the dose of olanzapine or switching to a different antipsychotic with a lower risk of EPS (e.g., quetiapine or clozapine).
• Educate the client and family about the potential side effects of antipsychotics and the importance of reporting any movement-related symptoms promptly.
• Encourage adherence to the prescribed medication regimen while discussing potential adjustments with the healthcare team.

✘Incorrect answer options:

Cogentin (benztropine mesylate). This is incorrect because Cogentin is an anticholinergic medication specifically used to treat or prevent EPS, including drug-induced Parkinsonism. It balances dopamine and acetylcholine levels, alleviating movement disorders caused by antipsychotics.

Benadryl (diphenhydramine). This is incorrect because Benadryl is an antihistamine with anticholinergic properties. Like Cogentin, it is sometimes used to manage EPS, particularly acute dystonic reactions, but it does not cause Parkinsonian symptoms.

Depakote (divalproex sodium). This is incorrect because Depakote is a mood stabilizer and anticonvulsant used to manage bipolar disorder, epilepsy, and migraines. It does not block dopamine receptors and is not associated with Parkinsonian symptoms.

EXPLANATION

✔Correct answer:

Difficulty distinguishing colors or changes in color vision. Ethambutol (Myambutol) is an antitubercular medication that can cause a rare but significant side effect: optic neuritis. This condition affects the optic nerve and can result in visual changes, including difficulty distinguishing between red and green or other color vision changes, as well as blurriness or reduced visual acuity. If left unreported and untreated, optic neuritis may lead to permanent vision loss. Therefore, it is critical that Mr. Harris promptly report any changes in his color vision or other visual symptoms to his healthcare provider. Early detection can allow for adjustment of the medication or discontinuation to prevent further damage.

While visual changes are the most serious and specific side effect of ethambutol, regular eye exams are recommended during therapy to monitor for these complications.

Taking ethambutol is like using a powerful tool to fix a problem, but if the tool starts damaging your eyesight (like blurring or changing colors), you need to stop using it immediately to prevent long-term harm.

Nurse Kelly should provide thorough education to Mr. Harris about the potential side effects of ethambutol and the importance of early reporting. Key actions include:

• Educate the client to monitor for visual changes, especially difficulty distinguishing colors or blurry vision, and report these symptoms immediately.
• Ensure that baseline and periodic visual acuity and color vision testing are conducted throughout therapy.
• Advise the client to avoid driving or operating machinery if visual disturbances occur until cleared by the healthcare provider.
• Monitor adherence to therapy, as stopping medication without guidance can lead to drug resistance in tuberculosis treatment.
• Encourage the client to attend all follow-up appointments for evaluation of vision and overall treatment response.

✘Incorrect answer options:

Stomach upset or gastric distress. While gastrointestinal upset can occur with ethambutol, it is a relatively minor and common side effect that can often be managed with supportive measures (e.g., taking the medication with food). It does not require immediate reporting.

Alterations in hearing ability. Hearing changes, such as tinnitus or hearing loss, are not associated with ethambutol but may occur with other antitubercular drugs like streptomycin or aminoglycosides. This is not a significant side effect of ethambutol.

Red discoloration of urine or other bodily fluids. Red or orange discoloration of urine, sweat, or tears is a harmless and expected side effect of rifampin, another common antitubercular medication. Ethambutol does not cause this discoloration.

EXPLANATION

✔Correct answer:

Meat, eggs, and dairy products. Nurse Karen should recommend meat, eggs, and dairy products as the best sources of vitamin B12. Vitamin B12, also known as cobalamin, is found naturally in animal-based foods. This vitamin plays a crucial role in red blood cell production, DNA synthesis, and proper functioning of the nervous system. People with pernicious anemia have difficulty absorbing vitamin B12 due to a lack of intrinsic factor in the stomach, which is necessary for B12 absorption. While dietary intake of B12 is beneficial, clients with pernicious anemia typically require lifelong B12 supplementation via injections or high-dose oral supplements to address this absorption issue. However, a diet rich in B12 can help maintain overall health.

Foods like red meat (beef, liver), poultry, fish (e.g., salmon, tuna), eggs, and dairy (e.g., milk, cheese, yogurt) are particularly rich in B12 and should be emphasized in dietary education.

Think of vitamin B12 as fuel for red blood cells, and animal-based foods like meat, eggs, and dairy are the "fuel stations" where you can get the best supply. Without this fuel, the body cannot run efficiently.

When educating clients with pernicious anemia, nurses should address both dietary sources of vitamin B12 and the need for supplemental therapy due to absorption issues.

• Educate the client about the importance of regular B12 injections or supplements since pernicious anemia prevents proper absorption of dietary B12.
• Encourage the inclusion of animal-based foods such as beef, chicken, fish, eggs, and dairy in the client’s diet to support overall nutrition.
• Monitor for signs of B12 deficiency, such as fatigue, pallor, glossitis (inflamed tongue), and neurological symptoms like tingling or numbness in extremities.
• Explain that plant-based sources of B12 (such as fortified cereals) are limited and less bioavailable compared to animal sources, making supplementation essential.
• Ensure follow-up lab tests are performed regularly to monitor B12 levels and assess treatment effectiveness.

✘Incorrect answer options:

Peanut butter, raisins, and molasses. This is incorrect because these foods do not contain significant amounts of vitamin B12. They may provide other nutrients such as iron, but they are not helpful in addressing B12 deficiency.

Broccoli, cauliflower, and cabbage. This is incorrect because these vegetables are not sources of vitamin B12. While they provide other vitamins like vitamin C and folic acid, they are plant-based and do not contain B12, which is only found in animal products and fortified foods.

Shrimp, legumes, and bran cereals. This is incorrect because legumes and bran cereals do not contain vitamin B12 naturally. Shrimp does contain B12, but it is not the most concentrated source compared to other animal-based foods like meat and dairy.

EXPLANATION

✔Correct answer:

By 30 months of age. Nurse Emily should explain to the mother that most children have all 20 of their primary teeth (baby teeth) by approximately 30 months of age. The eruption of primary teeth typically begins around 6 months of age with the lower central incisors and progresses in a predictable pattern. By the time the child is 2.5 years (30 months) old, they generally have a complete set of primary teeth, including the second molars.

The timeline for primary tooth eruption can vary slightly among children, but the general sequence is consistent. This information is important for parents to understand, as proper care of primary teeth is crucial for the child's oral health and development, including speech and proper alignment of the permanent teeth.

Think of a child’s primary teeth as puzzle pieces that slowly come together to complete the puzzle by about 30 months. The process starts with a few pieces at 6 months and finishes when the puzzle (full set of teeth) is completed at 2.5 years.

Nurses should provide anticipatory guidance about the normal timeline for tooth eruption and oral hygiene practices to parents or caregivers.

• Teach the mother to clean the baby’s teeth with a soft-bristled toothbrush or damp cloth once teeth begin to erupt.
• Encourage the avoidance of prolonged bottle-feeding or putting the baby to bed with a bottle to prevent dental caries ("baby bottle tooth decay").
• Recommend scheduling the child’s first dental visit by 12 months of age or within 6 months of the first tooth eruption.
• Advise using fluoride toothpaste in small amounts (a grain of rice-sized smear) once the child has teeth to prevent cavities.
• Provide information about the importance of a healthy diet in promoting strong teeth and gums.

✘Incorrect answer options:

By 12 months of age. This is incorrect because most children will only have about 4–8 primary teeth (typically central incisors and possibly lateral incisors) by 12 months of age. The full set of primary teeth is not yet developed.

By 18 months of age. This is incorrect because while many children will have a significant number of their primary teeth (e.g., 10–12 teeth, including molars) by 18 months, the second molars typically do not erupt until 20–30 months, making the set incomplete.

By 24 months of age. This is incorrect because, by 24 months, most children still lack the second molars, which are the last teeth to erupt. These usually come in by 30 months, completing the primary dentition.

EXPLANATION

✔Correct answer:

20–30 minutes three times a week. For clients with hypertension, aerobic exercise is a key component of managing blood pressure and improving cardiovascular health. Nurse Lisa should advise Mr. Carter to aim for a regimen of 20–30 minutes of moderate-intensity aerobic exercise at least three times a week, gradually increasing the duration and frequency as tolerated. Activities like brisk walking, cycling, swimming, or light jogging are effective at lowering blood pressure and improving overall cardiovascular health.

This recommendation aligns with guidelines from organizations such as the American Heart Association (AHA), which suggest starting with manageable durations and frequencies to reduce the risk of overexertion and build endurance over time. Exercise helps reduce blood pressure by improving vascular function, lowering systemic resistance, and enhancing heart efficiency.

Think of exercise for hypertension like watering a garden regularly. A little water (moderate exercise) given consistently helps the plants (heart and blood vessels) stay healthy without overwhelming the system, while skipping or overdoing it can lead to problems.

Nurses should ensure that clients understand how to incorporate exercise safely into their routine and monitor for signs of overexertion or other complications.

• Educate the client on recognizing signs of overexertion, such as dizziness, chest pain, or shortness of breath, and to stop exercising immediately if they occur.
• Advise the client to perform a warm-up and cool-down session before and after exercise to prevent injury and stabilize heart rate.
• Encourage hydration and proper footwear to ensure safety during exercise.
• Advise clients with hypertension to avoid high-intensity or isometric exercises (e.g., heavy weightlifting), as these can spike blood pressure.
• Discuss the importance of consistency, emphasizing that even moderate physical activity has long-term cardiovascular benefits.

✘Incorrect answer options:

45 minutes two times a week. This is incorrect because exercising only twice a week may not provide consistent cardiovascular benefits for blood pressure management. Aerobic exercise should ideally be done on more frequent days (at least three times a week).

1 hour four times a week. This is incorrect because starting with such a high intensity and frequency may be overwhelming for someone new to exercise and may increase the risk of injury or overexertion.

1 hour two times a week. This is incorrect because, while the duration is long, exercising only twice a week is insufficient to maintain consistent cardiovascular benefits. Consistency over duration is more critical for managing hypertension.

EXPLANATION

✔Correct answer:

The infant should not undergo circumcision. Hypospadias is a congenital condition in which the urethral opening is located on the underside of the penis instead of at the tip. In cases of hypospadias, circumcision is avoided at birth because the foreskin may be used later during surgical correction of the defect. The foreskin tissue is often utilized to reconstruct and reposition the urethral opening to the appropriate location, making it a critical part of the surgical process.

Surgical correction of hypospadias is usually performed when the child is between 6 and 18 months of age to minimize trauma and ensure proper urinary and sexual function as the child grows.

Imagine trying to repair a hole in a roof. You need all the material you can get to patch it properly. Similarly, the foreskin is like the extra material needed to fix the urethral opening, so it should not be removed at birth.

Nurse Julia should provide education and guidance to the parents about hypospadias and its management:

• Explain that circumcision should not be performed because the foreskin may be needed for surgical correction.
• Inform the parents that surgical correction is usually performed between 6 and 18 months of age to ensure proper urinary and sexual function later in life.
• Reassure the parents that hypospadias is a treatable condition with good outcomes after surgery.
• Provide instructions on proper diaper care to prevent infection and irritation in the affected area until surgery is completed.
• Encourage the parents to follow up with a pediatric urologist or surgeon to plan and schedule the surgical repair.

✘Incorrect answer options:

Surgical correction will be performed by 6 months of age. While surgery for hypospadias is often performed early, it is typically scheduled between 6 and 18 months of age, not necessarily by 6 months. The timing depends on the severity of the condition and the child’s health.

Surgery is postponed until the child reaches 6 years old. Postponing surgery until 6 years of age is not recommended because surgical repair is more effective and less traumatic when performed during infancy or early toddlerhood. Early correction reduces complications related to voiding, infection, and psychosocial effects.

Circumcision is recommended to help with voiding. Circumcision is not recommended in infants with hypospadias because the foreskin is often required for the surgical repair. Circumcision does not help with voiding and would complicate the corrective surgery.

EXPLANATION

✔Correct answer:

The usual treatment lasts 18–24 months. Tuberculosis (TB) treatment is a prolonged process because the bacteria, Mycobacterium tuberculosis, replicates slowly and is resilient to treatment. The usual treatment duration for active TB is 6–9 months, but in cases involving multidrug-resistant TB (MDR-TB) or extensively drug-resistant TB (XDR-TB), the treatment may last 18–24 months or longer. This extended duration ensures complete eradication of the bacteria, prevents relapse, and minimizes the development of drug resistance. Treatment usually involves a combination of first-line medications, such as isoniazid (INH), rifampin, pyrazinamide, and ethambutol, for the initial 2-month intensive phase, followed by a continuation phase with fewer drugs for several months.

Nurse Emily should emphasize the importance of completing the full course of treatment, even if Mr. Carter starts to feel better, to avoid relapse or development of drug-resistant TB.

Treating TB is like slowly chopping down a thick, resilient tree with a small axe. Even when the tree looks weak (symptoms improve), you must keep chopping until the tree is completely gone (bacteria eradicated), or it will grow back stronger.

Nurse Emily should educate Mr. Carter about the treatment plan and address any concerns about the lengthy duration of therapy:

• Explain the phases of TB treatment: the intensive phase (typically 2 months) and the continuation phase (lasting 4–7 months or longer for MDR-TB).
• Stress the importance of medication adherence to prevent drug resistance and relapse.
• Monitor for side effects of TB medications, such as hepatotoxicity (e.g., from isoniazid or rifampin), and educate Mr. Carter to report symptoms like jaundice, fatigue, or dark urine.
• Encourage regular follow-ups to assess treatment response, including sputum cultures and chest X-rays.
• Provide resources and emotional support to help the client cope with the long treatment duration and any lifestyle modifications required during this time.

✘Incorrect answer options:

Medication is typically stopped after 2 weeks. While TB symptoms may improve within a few weeks of starting treatment, the bacteria are not completely eradicated at this point. Stopping medications early increases the risk of relapse and the development of drug-resistant TB.

Medication will be required for the rest of his life. TB treatment is not lifelong. Once the prescribed regimen is completed and follow-up tests confirm the eradication of the bacteria, medication can be discontinued.

Re-evaluation in 1 month will determine if medication is still needed. Although regular follow-ups are critical, TB treatment involves a predetermined duration (e.g., 6–9 months for drug-sensitive TB or longer for MDR-TB). Medications are not stopped based solely on symptoms or a single re-evaluation.

EXPLANATION

✔Correct answer:

Abnormal breath sounds. The best indicator that suctioning is necessary in a client with ineffective airway clearance is the presence of abnormal breath sounds, such as gurgling, crackles, or rhonchi. These sounds indicate the presence of secretions in the airways that the client is unable to clear independently. Suctioning helps remove these secretions, improving airway patency, oxygenation, and ventilation. While other findings, such as oxygen saturation or respiratory rate, can signal respiratory compromise, they are not as direct and immediate an indicator of the need for suctioning as the presence of abnormal breath sounds.

In addition to abnormal breath sounds, other clinical signs that suctioning might be necessary include visible secretions in the mouth or airway, decreased oxygen saturation, cyanosis, or signs of increased work of breathing (e.g., nasal flaring, use of accessory muscles).

Think of the airway like a clogged drain. Abnormal breath sounds are like the gurgling noise from water trying to flow through the blockage, signaling that immediate clearing (suctioning) is needed to restore proper flow.

Nurse Carla should monitor for and address ineffective airway clearance by focusing on the following interventions:

• Assess lung sounds frequently to detect abnormal breath sounds that indicate retained secretions.
• Perform suctioning only when clinically indicated (e.g., abnormal breath sounds, visible secretions), as unnecessary suctioning can irritate the airway and increase the risk of infection.
• Preoxygenate the client before suctioning to minimize the risk of hypoxia.
• Encourage coughing and deep breathing to mobilize secretions and reduce the need for suctioning.
• Maintain proper hydration and humidification to keep secretions thin and easier to clear.

✘Incorrect answer options:

Oxygen saturation levels. While low oxygen saturation levels can indicate respiratory distress, they are not a direct or specific indicator of the need for suctioning. Decreased saturation can occur due to various factors, including poor ventilation or perfusion, and not all cases require suctioning.

The client’s respiratory rate. An increased respiratory rate may indicate distress but does not specifically signal the presence of airway secretions requiring suctioning. Respiratory rate changes can result from pain, anxiety, or other factors unrelated to secretions.

Results of arterial blood gas analysis. ABG results provide information about oxygenation, ventilation, and acid-base balance, but they do not specifically indicate the presence of retained secretions. ABG analysis is more useful for evaluating overall respiratory function and guiding long-term interventions rather than immediate suctioning needs.

EXPLANATION

✔Correct answer:

Regularly scheduled CBCs will be necessary. Clients taking Dilantin (phenytoin) must undergo regularly scheduled complete blood counts (CBCs) because phenytoin can cause bone marrow suppression, leading to complications such as leukopenia, thrombocytopenia, and anemia. Monitoring blood counts helps detect these issues early, allowing the healthcare team to adjust the medication dosage or intervene as needed to prevent serious complications. This routine bloodwork is essential for ensuring the client's safety while on long-term phenytoin therapy.

Additionally, regular monitoring of serum phenytoin levels is important to ensure the drug stays within the therapeutic range (10–20 mcg/mL), as both toxicity and subtherapeutic levels can pose risks. Toxicity can cause symptoms such as nystagmus, ataxia, confusion, and seizures.

Think of monitoring blood counts like checking the oil in a car engine—regular checks ensure everything runs smoothly, and catching problems early prevents major breakdowns.

Nurse Karen should include the following important information in Mr. Daniels's discharge instructions:

• Emphasize the need for regularly scheduled blood tests, including CBCs and serum phenytoin levels, to monitor for side effects and ensure therapeutic dosing.
• Educate the client about the signs and symptoms of blood disorders, such as easy bruising, bleeding gums, fatigue, or frequent infections, and advise reporting them immediately.
• Instruct the client on the importance of adherence to the prescribed dosing schedule, as skipping doses can increase seizure risk, and taking extra doses can lead to toxicity.
• Inform the client that good oral hygiene is essential, as phenytoin can cause gingival hyperplasia. Encourage regular dental checkups and brushing and flossing to prevent complications.
• Advise the client to avoid alcohol, which can increase the risk of phenytoin toxicity or reduce seizure control.

✘Incorrect answer options:

The medication may lead to dental staining. Phenytoin does not cause dental staining, but it can lead to gingival hyperplasia (overgrowth of gum tissue), which makes oral hygiene important. Dental staining is more commonly associated with other medications, such as tetracyclines.

Avoid consuming a high-carbohydrate diet. There is no specific dietary restriction for carbohydrates in clients taking phenytoin. However, a healthy, balanced diet is recommended for overall well-being and to prevent malnutrition, which can affect phenytoin metabolism.

The medication may cause drowsiness. Drowsiness can occur with some antiepileptic drugs, but it is not a common side effect of phenytoin when taken at therapeutic levels. Other side effects, such as nystagmus, ataxia, or confusion, are more indicative of phenytoin toxicity.

EXPLANATION

✔Correct answer:

Use tongs to safely place the implant into a lead-lined container. When a radioactive implant becomes dislodged, Nurse Sarah must prioritize safety for both herself and the client. Using tongs to place the implant into a lead-lined container is the appropriate action because it minimizes exposure to radiation. Lead-lined containers are designed to shield radiation, reducing the risk of harmful exposure to healthcare workers and others in the environment. Tongs provide a safe method for handling the implant, as direct contact with radioactive materials can result in radiation burns or systemic absorption of radiation.

The nurse should then notify the radiation safety officer (or the designated individual) at the facility and follow institutional protocols for managing dislodged implants. The client should be reassessed for any adverse effects, and steps should be taken to prevent further dislodgement.

Handling a radioactive implant is like safely dealing with a very hot metal object. You wouldn’t pick it up with your hands (to avoid burns); instead, you’d use a tool (tongs) to place it in a heat-proof container (lead-lined box) to prevent harm.

When caring for clients with radioactive implants, nurses must implement precautions to ensure safety while maintaining the integrity of the therapy.

• Limit time spent near the client to reduce radiation exposure and maintain a safe distance whenever possible.
• Provide shielding equipment, such as lead aprons or screens, for caregivers and visitors.
• Ensure the client remains on bedrest to reduce the risk of implant displacement.
• Educate the client and family about radiation precautions, including restricted visitation by pregnant individuals and children.
• Follow institutional policies for radiation safety, including regular monitoring of radiation levels with dosimeters.

✘Incorrect answer options:

Place the implant in a biohazard bag and send it to the lab. This is incorrect because radioactive materials require specific containment and cannot be handled or disposed of as standard biohazard waste. A lead-lined container is necessary to safely shield radiation.

Provide the client with gloves and ask her to reinsert it herself. This is incorrect because it places the client at unnecessary risk of radiation exposure and possible injury. Only trained healthcare personnel should handle radioactive implants.

Dispose of the implant in the commode and double-flush. This is incorrect and highly inappropriate. Radioactive materials must be handled according to strict safety guidelines and cannot be disposed of in the sewage system, as this could lead to contamination and environmental hazards.

EXPLANATION

✔Correct answer:

"Avoid abrupt discontinuation of this medication." It is critical for patients prescribed Cortone (cortisone), a corticosteroid, to avoid abrupt discontinuation of the medication. Corticosteroids suppress the hypothalamic-pituitary-adrenal (HPA) axis, and sudden cessation can lead to adrenal insufficiency, a potentially life-threatening condition characterized by hypotension, fatigue, and hypoglycemia. This occurs because the adrenal glands need time to resume normal cortisol production after prolonged corticosteroid use.

To prevent complications, cortisone must be tapered gradually under the supervision of a healthcare provider. This allows the body to adjust and the adrenal glands to regain their ability to produce cortisol naturally. Therefore, emphasizing the importance of adherence to the prescribed tapering schedule is crucial during discharge education.

Imagine the body’s adrenal glands as a backup generator. When taking corticosteroids, the generator is turned off because the medication provides the necessary power (cortisol). If the medication is stopped suddenly, the generator doesn’t have time to start up again, leaving the body without power (cortisol), which can be dangerous.

Nurses must provide comprehensive education about proper corticosteroid use, potential side effects, and the importance of tapering to ensure safe and effective management of systemic lupus erythematosus and other conditions.

• Emphasize the importance of taking the medication exactly as prescribed, including tapering schedules.
• Educate the patient to notify their healthcare provider immediately if they experience symptoms of adrenal insufficiency, such as severe fatigue, dizziness, or low blood pressure.
• Discuss strategies for managing side effects, such as weight gain or increased blood sugar, which are common with corticosteroids.
• Encourage regular follow-up appointments to monitor for long-term side effects, such as osteoporosis or immune suppression.
• Advise the patient to wear a medical alert bracelet indicating corticosteroid use, which can help in emergency situations.

✘Incorrect answer options:

"Take your medication only when symptoms worsen." This is incorrect because corticosteroids like Cortone must be taken consistently as prescribed. Skipping doses or taking the medication sporadically can lead to disease flare-ups and complications. Corticosteroids are not typically used on an "as-needed" basis.

"Limit your intake of high-protein foods while on this medication." This is incorrect because there is no specific requirement to limit high-protein foods while taking corticosteroids. In fact, adequate protein intake can help counteract muscle wasting, a possible side effect of corticosteroid use.

"Skip doses if you experience nausea or vomiting." This is incorrect because skipping doses can disrupt the therapeutic effect of corticosteroids and lead to adrenal insufficiency. If the patient experiences nausea or vomiting, they should contact their healthcare provider to discuss alternatives or adjustments to their regimen.

EXPLANATION

✔Correct answer:

Position the client prone for 15–30 minutes twice daily. The most appropriate action to prevent contractures in a client with an above-the-knee amputation (AKA) is to position the client prone for 15–30 minutes twice daily. This positioning helps to stretch the hip flexor muscles, which are prone to becoming tight and contracted due to prolonged sitting or improper positioning. Contractures, particularly hip flexion contractures, are a common complication in clients with AKAs and can hinder the proper fitting and use of prosthetics.

When the client lies prone, the hip is extended, which counteracts the tendency of the hip flexors to shorten. This practice is particularly important because contractures can lead to difficulties in mobility, rehabilitation, and prosthetic fitting. It also promotes proper alignment of the residual limb and supports the rehabilitation process.

Think of the hip joint as a door hinge. If you keep the door slightly open for a long time (sitting position), the hinge can get stuck in that position (contracture). Lying prone (fully extending the hinge) helps prevent it from becoming stiff and ensures smooth movement later.

Preventing contractures is a key aspect of care for clients with amputations. Nurses must implement strategies that promote mobility and proper limb positioning.

• Encourage the prone position daily to prevent hip flexion contractures.
• Avoid prolonged sitting or elevation of the residual limb, as these positions promote contracture development.
• Educate the client and family about proper limb positioning and the importance of stretching exercises.
• Work collaboratively with physical and occupational therapists to develop a tailored rehabilitation program.
• Instruct the client on using assistive devices to maintain proper alignment and mobility.

✘Incorrect answer options:

Elevate the foot of the bed using shock blocks. This is incorrect because elevating the foot of the bed can promote hip and knee flexion, increasing the risk of contractures. It is essential to keep the residual limb in a neutral, extended position.

Use trochanter rolls on either side of the amputated limb. This is incorrect because trochanter rolls are typically used to prevent external rotation of the hips in clients who are bedridden. They do not address the prevention of hip flexion contractures in AKA clients.

Keep the residual limb elevated on two pillows. This is incorrect because prolonged elevation of the residual limb on pillows places the hip in a flexed position, increasing the risk of contracture development. Elevation is only recommended briefly and for specific purposes, such as reducing swelling, and should not be prolonged.

EXPLANATION

✔Correct answer:

Anemia or another condition affecting red blood cells. An HbA1c of 2.5% is extremely low and does not accurately reflect the client’s glycemic control. Such a result suggests that anemia or another condition affecting red blood cells may be interfering with the accuracy of the HbA1c test. Hemoglobin A1c measures the percentage of glycosylated hemoglobin in the blood, which reflects average blood glucose levels over the past 2–3 months. Conditions such as iron deficiency anemia, hemolytic anemia, recent blood transfusions, or chronic kidney disease can alter the lifespan of red blood cells and falsely lower HbA1c values, leading to results that do not correlate with the client's true glycemic status.

In this case, the abnormally low HbA1c warrants further investigation to identify potential underlying hematologic conditions. Nurse Julia should collaborate with the healthcare provider to determine if additional testing, such as a complete blood count (CBC) or iron studies, is needed.

Think of HbA1c as a thermometer for blood sugar control. If the thermometer itself is broken or malfunctioning (due to anemia or other conditions), the readings won’t accurately reflect the actual temperature (blood sugar levels).

Nurses should assess for signs of anemia or other hematologic issues while educating the client about the limitations of HbA1c in certain conditions.

• Evaluate the client for symptoms of anemia, such as fatigue, pallor, shortness of breath, or dizziness, which may indicate a red blood cell disorder.
• Consult the healthcare provider to perform additional diagnostic tests, such as a CBC, reticulocyte count, or serum ferritin, to investigate possible causes of the abnormal HbA1c.
• Discuss alternative methods for assessing blood glucose control, such as frequent self-monitoring of blood glucose (SMBG) or a fructosamine test, which reflects average glucose levels over the past 2–3 weeks.
• Ensure the client understands that a low HbA1c result may not always mean good glycemic control and that follow-up testing is necessary.
• Collaborate with the healthcare team to adjust the diabetes management plan based on accurate diagnostic findings.

✘Incorrect answer options:

Poor glycemic control over the past 3 months. This is incorrect because a low HbA1c, such as 2.5%, does not indicate poor glycemic control. Poor glycemic control typically corresponds to high HbA1c values (above 7%), which suggest hyperglycemia.

Well-controlled diabetes mellitus. This is incorrect because an HbA1c of 2.5% is abnormally low and does not represent good diabetes control. Such a result likely indicates a condition interfering with HbA1c accuracy, not actual blood glucose levels.

Prediabetes. This is incorrect because prediabetes is defined by an HbA1c range of 5.7%–6.4%, which is significantly higher than 2.5%. The low value here suggests another underlying issue rather than prediabetes.

EXPLANATION

✔Correct answer:

Swimming. Swimming is the best activity for Mia, as it promotes joint movement and flexibility without putting excessive strain on the joints. For children with juvenile rheumatoid arthritis (JRA), low-impact, non-weight-bearing exercises are ideal because they help maintain joint function, muscle strength, and range of motion while minimizing the risk of joint pain or inflammation.

The buoyancy of water reduces stress on weight-bearing joints, such as the knees, hips, and ankles, while also providing gentle resistance that improves muscle strength. Swimming or water aerobics also improves cardiovascular health, making it an excellent overall exercise choice for children with JRA.

Imagine your joints as hinges on a door. Over time, those hinges can get stiff if they aren't moved gently and regularly. Swimming is like applying oil to the hinges—it keeps them moving smoothly without causing extra wear and tear.

Nurses should encourage physical activity tailored to the child’s condition while providing education on joint protection and pain management.

• Encourage low-impact activities such as swimming, biking, or walking to maintain joint mobility and overall health.
• Teach the child and caregivers about the importance of regular exercise to prevent joint stiffness and muscle atrophy.
• Educate on using heat packs or warm baths before exercise to reduce stiffness and improve joint flexibility.
• Advise avoiding high-impact activities that can worsen joint pain or lead to injury.
• Encourage participation in enjoyable activities to promote emotional well-being and social interaction, as chronic conditions like JRA can affect mental health.

✘Incorrect answer options:

Playing video games. This is incorrect because playing video games is a sedentary activity that does not promote joint movement or physical activity. Prolonged periods of inactivity can lead to increased joint stiffness and decreased range of motion in children with JRA.

Solving crossword puzzles. This is incorrect because while crossword puzzles are beneficial for mental stimulation, they do not provide the physical activity needed to maintain joint function and mobility in children with JRA.

Playing slow-pitch softball. This is incorrect because even though softball may seem less intense, it involves running, quick movements, and repetitive impact on the joints, which could exacerbate joint pain or inflammation in a child with JRA.

EXPLANATION

✔Correct answer:

Advise the client to avoid tub baths for 48 hours. After a laparoscopic cholecystectomy, it is important to keep the surgical incision sites clean and dry to prevent infection. Nurse Mia should instruct Mrs. Taylor to avoid tub baths for at least 48 hours, as submerging the incisions in water increases the risk of infection. Instead, the client can shower and gently pat the incision sites dry. The incisions are small and usually heal quickly, but proper care during the initial healing period is essential.

Tub baths should be avoided until the surgeon confirms that the incision sites have healed, which is typically after the follow-up visit. Additionally, clients should watch for signs of infection, such as redness, swelling, or discharge from the incision sites.

Think of the incision sites like small scabs on the skin. If you soak a scab in water too soon, it may loosen and increase the chance of bacteria entering, which can lead to infection. Keeping the area dry helps it heal properly.

Education during discharge is critical to ensure the client understands how to care for themselves and avoid complications following surgery.

• Teach the client to monitor the incision sites for signs of infection, such as redness, warmth, or discharge.
• Advise the client to avoid heavy lifting or strenuous activities for about 1–2 weeks, or as directed by their surgeon.
• Encourage early ambulation to prevent complications like gas pain and promote faster recovery.
• Instruct the client to follow a light diet initially, avoiding fatty or greasy foods to prevent digestive discomfort.
• Ensure the client knows the importance of attending their follow-up appointment to assess healing and review further care.

✘Incorrect answer options:

Inform the client to expect clay-colored stools. This is incorrect because clay-colored stools indicate a potential bile flow obstruction, which is not a normal finding after a laparoscopic cholecystectomy. This symptom should be reported immediately to the healthcare provider.

Explain that lower abdominal pain is normal for the next week. This is incorrect because post-operative pain following a laparoscopic cholecystectomy is usually located in the upper abdomen, shoulder, or back due to residual carbon dioxide gas used during the procedure. Lower abdominal pain is not typical and could indicate a complication, such as infection or bowel injury, which would require immediate medical attention.

Encourage the client to resume a regular diet within 24 hours. This is incorrect because while most clients can tolerate food soon after surgery, they are typically advised to start with a light diet and avoid fatty or greasy foods for a few days. This helps prevent digestive upset as the body adjusts to the absence of the gallbladder.

EXPLANATION

✔Correct answer:

Rolling over. At around 4 months of age, infants typically begin to develop the ability to roll over, a significant developmental milestone. While this is an exciting step, it also introduces a new safety risk because the infant can accidentally roll off elevated surfaces, such as changing tables, beds, or couches. Parents may not anticipate the sudden movement, which increases the likelihood of falls and injuries. Therefore, rolling over represents the developmental milestone that puts infants at the greatest risk for injury at this age.

Nurse Ava should emphasize the importance of never leaving the baby unattended on elevated surfaces and ensuring that the baby is placed on a safe, low surface or in a secure environment when unattended. This precaution helps prevent falls and promotes safety as the baby continues to develop motor skills.

Think of a rolling baby like a ball on a flat surface—once they can move, they might roll unexpectedly, and if the surface is high, the ball (or baby) can fall and get hurt.

Nurse Ava should provide the following safety tips to the new parents:

• Always keep a hand on the baby when they are on an elevated surface, such as a changing table.
• Change the baby on a flat, low surface if possible, and never leave the baby unattended, even for a moment.
• Ensure the baby’s crib or play area is free of hazards and has appropriate safety rails.
• Place the baby on their back to sleep on a firm mattress with no loose bedding or toys to reduce the risk of Sudden Infant Death Syndrome (SIDS).
• Encourage tummy time while the baby is awake and supervised to strengthen muscles for further motor development.

✘Incorrect answer options:

Transferring objects between hands. This milestone usually occurs later, around 6–7 months of age. While it is important for motor skill development, it does not pose as significant a risk for injury at 4 months compared to rolling over.

Crawling. Crawling typically begins around 6–9 months of age. While it increases mobility and poses new risks (e.g., access to hazardous areas or items), it is not relevant to a 4-month-old baby.

Standing upright. Standing upright occurs much later, around 9–12 months, as part of the preparation for walking. At 4 months, this milestone is not yet relevant.

EXPLANATION

✔Correct answer:

To inhibit platelet aggregation and prevent clots. Aspirin is prescribed for Mr. Lee because it acts as an antiplatelet agent, inhibiting platelet aggregation and reducing the formation of blood clots. Transient ischemic attacks (TIAs) are often caused by temporary reductions in blood flow to the brain due to small clots or emboli. By preventing platelets from clumping together, aspirin lowers the risk of clot formation in blood vessels, thereby reducing the likelihood of future TIAs or ischemic strokes.

Aspirin achieves this by irreversibly inhibiting the enzyme cyclooxygenase-1 (COX-1), which is involved in the production of thromboxane A2, a substance that promotes platelet aggregation. This mechanism makes aspirin an essential medication in the secondary prevention of TIAs and ischemic strokes.

Think of platelets as cars on a bridge. If they pile up (aggregate), they create a traffic jam (clot) that blocks blood flow. Aspirin works like a traffic officer, stopping the cars from piling up and keeping the bridge clear for smooth blood flow.

Nurse Jenna should provide education and monitor Mr. Lee for potential side effects and complications related to aspirin therapy:

• Teach the client about the purpose of aspirin and the importance of taking it consistently as prescribed.
• Monitor for signs of bleeding, such as bruising, black tarry stools, or prolonged bleeding from minor cuts, as aspirin increases bleeding risk.
• Educate the client to avoid taking other nonsteroidal anti-inflammatory drugs (NSAIDs) or anticoagulants without consulting their healthcare provider, as these can increase bleeding risk.
• Encourage the client to report any unusual symptoms, such as ringing in the ears (tinnitus), which can be a sign of aspirin toxicity.
• Ensure the client understands lifestyle modifications, such as controlling hypertension and quitting smoking, to further reduce the risk of TIAs or strokes.

✘Incorrect answer options:

To relieve or prevent headaches. Although aspirin can be used for pain relief or to treat headaches, its use in this scenario is for its antiplatelet properties to prevent clot formation, not for headache management.

To enhance blood clotting. Aspirin does the opposite—it inhibits clotting by preventing platelet aggregation. Enhancing clotting would be counterproductive in the context of preventing TIAs, which are caused by clots reducing cerebral blood flow.

To reduce the risk of cerebral oxygen deprivation. While preventing clots can indirectly reduce the risk of cerebral oxygen deprivation (ischemia), aspirin’s primary role is to inhibit platelet aggregation. Its effect on oxygen deprivation is secondary to its antiplatelet action.

EXPLANATION

✔Correct answer:

Reduced production of erythropoietin. The primary cause of anemia in clients with chronic renal failure (CRF) is reduced production of erythropoietin, a hormone produced by the kidneys. Erythropoietin stimulates the bone marrow to produce red blood cells (RBCs). In chronic renal failure, the damaged kidneys are unable to produce adequate amounts of erythropoietin, leading to a decrease in RBC production and resulting in anemia. This type of anemia is referred to as anemia of chronic disease or renal anemia.

Anemia in chronic renal failure can contribute to symptoms such as fatigue, pallor, weakness, and shortness of breath due to reduced oxygen-carrying capacity of the blood. Addressing this anemia typically involves the administration of synthetic erythropoietin (e.g., epoetin alfa) along with iron supplements to support RBC production.

The kidneys act like the "managers" of a factory, signaling the bone marrow (the "workers") to produce red blood cells. In chronic renal failure, the managers (kidneys) fail to send the signals (erythropoietin), so the workers don’t know they need to make more red blood cells.

Nurse Maria should focus on managing anemia in clients with chronic renal failure by collaborating with the healthcare team and monitoring for complications:

• Administer synthetic erythropoietin (e.g., epoetin alfa or darbepoetin alfa) as prescribed to stimulate RBC production.
• Monitor hemoglobin and hematocrit levels to assess response to therapy.
• Ensure adequate iron stores by administering oral or IV iron supplements, as iron is necessary for effective erythropoiesis.
• Educate the client about dietary sources of iron (e.g., lean meats, beans, dark green vegetables) and the importance of adhering to treatment.
• Monitor for symptoms of anemia, such as fatigue, pallor, dizziness, and tachycardia, and provide supportive care.

✘Incorrect answer options:

Poor absorption of iron. While iron deficiency can cause anemia, it is not the primary cause of anemia in chronic renal failure. In this condition, the anemia is due to insufficient erythropoietin production, although iron supplementation may still be necessary to support RBC production.

Increased destruction of red blood cells. Increased RBC destruction is associated with hemolytic anemia, not the anemia of chronic renal failure. In CRF, the problem lies with reduced production of RBCs, not their destruction.

A deficiency in intrinsic factor production. A lack of intrinsic factor leads to pernicious anemia, a type of anemia caused by impaired absorption of vitamin B12. This is unrelated to chronic renal failure.

EXPLANATION

✔Correct answer:

Confirming if the client has any allergies to shellfish. Before an intravenous pyelogram (IVP), it is crucial to determine whether the client has a history of allergies, particularly to iodine or shellfish, because the contrast dye used in the procedure contains iodine. Allergic reactions to iodine-based contrast media can range from mild symptoms (e.g., rash, itching) to severe, life-threatening anaphylaxis. Identifying allergies allows the healthcare team to take precautions, such as pre-medicating with antihistamines or corticosteroids, or selecting an alternative imaging study that does not require contrast.

This intervention is a priority because it directly addresses the risk of an immediate, potentially life-threatening reaction during the procedure. Ensuring the client’s safety through proper screening for allergies takes precedence over other interventions.

Think of checking for iodine allergies as making sure you know whether a person is allergic to an ingredient before serving them food. If they are allergic, you can avoid using that ingredient to prevent harm.

In addition to assessing for allergies, Nurse Sarah should implement other interventions to ensure the safety and effectiveness of the IVP:

• Verify that the client has fasted for at least 8 hours before the procedure, as a full stomach can interfere with imaging and increase the risk of nausea from the dye.
• Explain the procedure, including that the client may feel a warm sensation or metallic taste when the dye is injected, to reduce anxiety.
• Ensure adequate hydration before and after the procedure to protect kidney function by flushing out the contrast dye, especially for clients with renal impairment.
• Monitor renal function by checking baseline blood urea nitrogen (BUN) and creatinine levels, as contrast dye can cause nephrotoxicity in vulnerable clients.
• Observe for signs of a reaction during and after the procedure, such as difficulty breathing, rash, or swelling, and be prepared to administer emergency medications if needed.

✘Incorrect answer options:

Offering the client a preferred meal for dinner. While ensuring the client’s nutritional needs are met is important, this is not relevant to the safety of the IVP and does not take priority over assessing for allergies or other preparation steps.

Promoting increased fluid intake the evening before. Increased fluid intake is often encouraged after the procedure to help flush the contrast dye from the kidneys. However, pre-procedure hydration, while important, is not as critical as identifying an allergy that could lead to an immediate adverse reaction during the IVP.

Explaining what the client can expect during the test. Client education is important to reduce anxiety and improve cooperation during the procedure, but it is not the highest priority. Ensuring client safety by screening for allergies takes precedence over education.

EXPLANATION

✔Correct answer:

With meals and snacks. Creon (pancrelipase) is a pancreatic enzyme replacement therapy used for clients with cystic fibrosis (CF) to aid in the digestion of fats, proteins, and carbohydrates. In clients with CF, the pancreas does not produce sufficient digestive enzymes, leading to malabsorption and malnutrition. To be effective, Creon must be administered with meals and snacks, as it works in conjunction with the food being digested. This timing ensures that the enzymes are present in the small intestine to help break down food, promoting better nutrient absorption and reducing gastrointestinal symptoms such as bloating, fatty stools (steatorrhea), and abdominal discomfort.

Administering Creon outside of mealtime would diminish its effectiveness, as there would be little or no food in the digestive tract for the enzymes to act on.

Think of Creon like dishwashing detergent—it only works when dishes (food) are present. Adding the detergent when there are no dishes won’t clean anything, just like taking Creon without food won’t help with digestion.

Nurses should provide detailed education to families about proper administration of Creon and its role in managing cystic fibrosis.

• Instruct parents to give Creon immediately before or during meals and snacks, including beverages like milk if consumed in large amounts.
• Advise parents to adjust the dose as prescribed based on the size of the meal or snack (e.g., more enzymes for larger meals and fewer for snacks).
• Ensure that Jacob takes the medication with water or another liquid to help swallow the capsules and prevent irritation to the mouth or esophagus.
• Inform parents that the capsules should not be crushed or chewed. For younger children or those unable to swallow capsules, they can open the capsule and sprinkle the contents on a small amount of soft, acidic food like applesauce (not on alkaline foods, which inactivate the enzymes).
• Encourage parents to monitor for signs of malabsorption, such as foul-smelling or greasy stools, which may indicate the need to adjust the dose.

✘Incorrect answer options:

At bedtime. This is incorrect because Creon must be taken with food to work effectively. Administering it at bedtime without a meal would not provide any benefit.

Twice daily. This is incorrect because Creon is not dosed on a fixed schedule like some medications. Instead, it is dosed based on the number of meals and snacks consumed throughout the day.

Once daily in the morning. This is incorrect because one dose in the morning would not provide sufficient enzyme coverage for meals and snacks later in the day. Creon must be taken with every meal and snack to ensure proper digestion.

EXPLANATION

✔Correct answer:

Elevate the client’s right arm on pillows. After a right total mastectomy, it is essential to reduce swelling (lymphedema) and promote circulation in the affected arm. Elevating the right arm on pillows helps to facilitate venous and lymphatic return, preventing fluid accumulation in the arm. This is particularly important because the removal of axillary lymph nodes during surgery can disrupt lymphatic drainage, making the client prone to lymphedema.

Proper positioning also helps reduce discomfort and prevent complications, such as stiffness or impaired mobility, by encouraging natural circulation. Elevation should be done with the arm slightly above the level of the heart and supported comfortably to avoid strain.

Think of the lymphatic system like a drainage pipe. After surgery, the pipe may get clogged, causing fluid buildup. Elevating the arm works like gravity pulling the fluid away from the arm, helping the pipe (lymph system) flow better.

Nurses play a critical role in preventing post-mastectomy complications by educating the client on proper arm positioning and exercise.

• Elevate the affected arm on pillows to reduce swelling and improve lymphatic drainage.
• Encourage early, gentle arm exercises (e.g., squeezing a ball, light stretching) to prevent stiffness and improve circulation, as prescribed by the healthcare provider.
• Avoid blood pressure measurements, IV insertions, or blood draws on the affected arm to prevent trauma or worsening lymphedema.
• Educate the client about wearing loose clothing and avoiding tight bands or jewelry on the affected arm.
• Monitor for signs of lymphedema, such as persistent swelling, tightness, or discomfort in the affected arm, and report to the provider if necessary.

✘Incorrect answer options:

Place the client’s right arm in a dependent sling. This is incorrect because placing the arm in a dependent position (hanging downward) increases fluid accumulation and worsens swelling, as gravity will pull the fluid into the arm instead of promoting drainage.

Keep the client’s right arm resting flat on the bed beside her. This is incorrect because keeping the arm flat does not promote venous or lymphatic return effectively. Without elevation, swelling may persist or worsen.

Position the client’s right arm across her body. This is incorrect because positioning the arm across the body does not facilitate proper lymphatic or venous drainage. It can also restrict mobility and cause discomfort.

EXPLANATION

✔Correct answer:

Wandering and getting lost in familiar places. Wandering and getting lost in familiar places is a hallmark symptom of stage III Alzheimer’s disease, which corresponds to the moderate stage of the condition. At this stage, cognitive decline progresses to the point where individuals lose their ability to navigate even previously familiar environments, posing safety concerns. This behavior is linked to memory loss, disorientation, and impaired spatial reasoning caused by progressive neuronal degeneration in the hippocampus and other parts of the brain responsible for memory and spatial awareness.

In stage III Alzheimer’s, other symptoms include significant difficulty with communication, increased confusion about time and place, and requiring help with personal care activities. These changes mark a decline from earlier stages, where symptoms may be milder and involve memory lapses or difficulty with complex tasks.

Imagine the brain as a detailed road map. In stage III Alzheimer’s, key parts of this map become faded or unreadable (neuronal degeneration). As a result, the person can no longer find their way—even in places they know well—leading to wandering and getting lost.

Nurses should prioritize interventions aimed at ensuring the patient’s safety and supporting their cognitive abilities while providing emotional support to both the patient and their family.

• Ensure a safe environment by removing hazards and installing safety devices, such as door locks or alarms, to prevent wandering.
• Use clear and simple communication to reduce the patient’s confusion and agitation.
• Encourage the use of identification bracelets in case the patient gets lost.
• Develop a daily routine to promote familiarity and reduce disorientation.
• Provide caregiver education on managing wandering behaviors and recognizing signs of progression.

✘Incorrect answer options:

Occasional forgetfulness about recent events. This symptom is more typical of the early stages of Alzheimer’s disease (stage I). At that stage, memory lapses are minor, and individuals are usually still capable of functioning independently.

Inability to recognize close family members. This symptom is characteristic of the late stage of Alzheimer’s disease (stage IV), where cognitive and functional abilities are severely impaired, and patients lose the ability to recognize loved ones or even themselves.

Difficulty managing complex tasks, such as finances. This symptom is associated with the early stage of Alzheimer’s disease (stage II), where cognitive decline begins to interfere with higher-order tasks, but basic daily functioning remains intact.