NCLEX- PN Practice Exam 6

EXPLANATION

✔Correct answer:

Cherry-red urine that gradually clears over time. After extracorporeal shock wave lithotripsy (ESWL), cherry-red urine is an expected finding due to the minor trauma caused by the shock waves as they break up kidney or ureteral stones. This procedure can result in small injuries to the urinary tract lining, leading to temporary hematuria (blood in the urine). The cherry-red coloration typically clears within 24-48 hours as the urinary tract heals. Nurse Sarah should monitor the client’s urinary output to ensure that bleeding diminishes over time and watch for signs of complications, such as persistent or worsening bleeding.

ESWL uses high-energy sound waves to fragment kidney stones into smaller pieces that can be naturally passed through the urinary tract. During this process, minor damage to blood vessels and tissues in the urinary system is common, resulting in transient hematuria. This is a normal and expected outcome unless the hematuria persists or is accompanied by large clots, which may indicate complications requiring medical attention.

Think of the urinary tract as a smooth pipe. During lithotripsy, the process of breaking the stones creates small scratches (minor trauma) inside the pipe, causing the liquid (urine) to appear slightly red. Over time, as the scratches heal, the liquid clears.

Nurse Sarah should provide appropriate post-lithotripsy care and monitor for complications:

• Encourage increased fluid intake (2-3 liters/day) to flush out stone fragments and help clear hematuria more quickly.
• Instruct the client to strain all urine to catch stone fragments for analysis, which can guide future prevention strategies.
• Monitor for worsening hematuria, the presence of clots, or any accompanying symptoms like severe pain or fever, which should be reported immediately.
• Educate the client to avoid strenuous activities for a few days, as this could exacerbate bleeding or delay healing.
• Provide reassurance that mild hematuria is a normal finding but emphasize the importance of seeking medical attention for unusual symptoms.

✘Incorrect answer options:

Orange-tinted urine containing small calculi fragments. While small stone fragments are expected after lithotripsy, orange-tinted urine is not typical. Orange urine may indicate medication effects (e.g., phenazopyridine) but is not associated with the immediate post-lithotripsy period.

Dark red urine that becomes cloudy in appearance. Dark red and cloudy urine is not a normal finding and may suggest infection, significant bleeding, or urine stasis, which require immediate medical attention. This finding is concerning and should not be expected post-lithotripsy.

Smoky-colored urine with an elevated specific gravity. Smoky-colored urine is more commonly associated with glomerulonephritis or other kidney conditions involving blood and protein in the urine. Elevated specific gravity usually indicates concentrated urine due to dehydration, which is not directly related to lithotripsy outcomes.

EXPLANATION

✔Correct answer:

Keep some crackers at your bedside to eat before getting out of bed. Eating a small snack, such as crackers, before getting out of bed can help reduce morning sickness by stabilizing blood sugar levels, which often drop during the night and can contribute to nausea. This suggestion helps prevent the stomach from becoming completely empty, which can also exacerbate nausea. Crackers are a light, bland food that is easy to digest and less likely to trigger nausea.

This is a well-supported strategy for managing morning sickness in pregnancy, as it helps ease the transition from lying down to being upright without overwhelming the digestive system.

Think of your stomach as a car engine. Running the engine (getting out of bed) with no fuel (empty stomach) can cause it to sputter and stall (nausea). A quick snack like crackers works like adding just enough fuel to start smoothly.

Nurses should educate pregnant clients on strategies to manage morning sickness and provide reassurance that this is a common symptom in early pregnancy.

• Encourage small, frequent meals throughout the day to prevent the stomach from becoming empty.
• Advise eating bland, easy-to-digest foods like crackers, toast, or bananas, especially first thing in the morning.
• Suggest avoiding strong-smelling, spicy, or greasy foods, which can worsen nausea.
• Recommend drinking fluids between meals rather than with meals to avoid overfilling the stomach.
• If morning sickness becomes severe or persistent (hyperemesis gravidarum), advise the client to contact their healthcare provider for further evaluation and treatment.

✘Incorrect answer options:

Drink a glass of whole milk before bedtime to help prevent nausea. This is incorrect because whole milk is heavy and can be difficult to digest, which may worsen nausea instead of preventing it.

Skip breakfast and focus on eating a bigger lunch and dinner. This is incorrect because skipping meals, especially breakfast, can worsen nausea by leaving the stomach empty for an extended period. Small, frequent meals are more effective.

Add a few teaspoons of sugar to a glass of orange juice and drink it. This is incorrect because orange juice is acidic and adding sugar may further irritate the stomach, potentially triggering or worsening nausea.

EXPLANATION

✔Correct answer:

Weakness that worsens as the day progresses. Myasthenia gravis (MG) is a chronic autoimmune neuromuscular disorder characterized by weakness in the skeletal muscles, which are responsible for voluntary movement. This condition occurs due to the production of autoantibodies that block or destroy acetylcholine receptors at the neuromuscular junction, impairing the transmission of nerve impulses to the muscles. One hallmark symptom of MG is muscle weakness that worsens with activity and improves with rest, known as fatigability. As the day progresses, repeated muscle use leads to more severe weakness, which can significantly impact daily activities such as speaking, chewing, and walking.

Clients with MG commonly present with ptosis (drooping eyelid), diplopia (double vision), difficulty swallowing (dysphagia), and generalized muscle weakness that worsens throughout the day. This progression is due to the depletion of available acetylcholine as muscles are used repeatedly without adequate recovery time.

Imagine your muscles as a phone with a battery that depletes more quickly the more you use it. In myasthenia gravis, it's like having a faulty charger—your body can’t properly "recharge" the muscles during activity because the signals (like electricity) aren’t reaching the muscles effectively. So as you keep using the phone (muscles) throughout the day, the battery drains faster, leaving the muscles weaker by evening unless they "rest" to recover some energy.

When assessing and managing a client with suspected or confirmed MG, the nurse should prioritize interventions that promote rest, optimize muscle strength, and prevent complications.

• Assess for ptosis, diplopia, and other signs of muscle weakness during the day.
• Monitor respiratory status closely, as respiratory muscles may be affected in severe cases, leading to myasthenic crisis.
• Educate the client to schedule physical activities during times of optimal muscle strength, such as early in the day.
• Administer anticholinesterase medications (e.g., pyridostigmine) as prescribed to enhance acetylcholine availability at the neuromuscular junction.
• Encourage small, frequent meals to reduce fatigue during eating and prevent aspiration.

✘Incorrect answer options:

Visual symptoms such as diplopia. While diplopia (double vision) is indeed a common symptom of MG, it is not the hallmark feature. Muscle weakness with fatigability, especially worsening as the day progresses, is the most definitive characteristic of this condition.

Paralysis that progresses upward with loss of motor control. This description aligns with Guillain-Barré syndrome, an autoimmune condition affecting the peripheral nervous system, not MG. Guillain-Barré typically presents with ascending paralysis rather than fatigable weakness.

Stiff, jerky movements and impaired coordination. These symptoms are more indicative of conditions like Parkinson's disease or cerebellar disorders, which involve rigidity, tremors, and coordination deficits rather than the fatigable muscle weakness seen in MG.

EXPLANATION

✔Correct answer:

Atorvastatin (Lipitor). Atorvastatin (Lipitor) is a lipid-lowering medication from the statin class that is metabolized primarily in the liver. It carries a risk of hepatotoxicity and liver enzyme elevation, which can exacerbate liver damage in patients with impaired liver function, such as those with hepatitis A. Hepatitis A is an acute liver infection caused by the hepatitis A virus, leading to inflammation and reduced liver function during the illness. Because the liver's ability to metabolize drugs is compromised in hepatitis, administering atorvastatin during this time could worsen liver injury or impair recovery.

In patients with acute liver disease, such as hepatitis A, statins like atorvastatin should generally be discontinued or avoided until liver function normalizes. This recommendation is based on the drug's reliance on hepatic metabolism and its potential to increase liver enzyme levels, which can already be elevated in hepatitis.

Think of the liver as a factory that processes medications like atorvastatin. During hepatitis, the factory is damaged and struggling to work. Giving atorvastatin during this time adds more stress to the factory, potentially causing further damage.

Nurses should carefully monitor patients with liver dysfunction for potential hepatotoxicity and collaborate with the healthcare provider to adjust medications.

• Flag medications metabolized by the liver, such as atorvastatin, for temporary discontinuation during acute liver conditions.
• Monitor liver function tests (LFTs), including ALT, AST, and bilirubin levels, to assess the extent of liver injury and recovery.
• Educate the patient on avoiding other hepatotoxic substances, such as alcohol or over-the-counter medications containing acetaminophen.
• Consult the healthcare provider regarding resuming atorvastatin once liver function has stabilized.
• Provide patient education on the signs and symptoms of hepatotoxicity, such as jaundice, fatigue, dark urine, or abdominal pain, and the importance of reporting them promptly.

✘Incorrect answer options:

Omeprazole (Prilosec). This is incorrect because omeprazole, a proton pump inhibitor (PPI), is metabolized in the liver but is not commonly associated with hepatotoxicity. It is considered safe for use in patients with liver dysfunction.

Levothyroxine (Synthroid). This is incorrect because levothyroxine, a thyroid hormone replacement, is primarily metabolized in tissues outside the liver and does not pose a significant risk of hepatotoxicity. It is safe to continue during hepatitis A unless otherwise indicated.

Conjugated estrogens (Premarin). This is incorrect because conjugated estrogens are metabolized in the liver but do not significantly increase the risk of liver damage in short-term use. While caution is required in severe chronic liver disease, temporary discontinuation is generally not necessary during acute hepatitis.

EXPLANATION

✔Correct answer:

The child should avoid playing on his rocking horse or similar toys. After a hypospadias repair, it is crucial to avoid activities that can place pressure on the surgical site, such as riding a rocking horse, bicycle, or other straddle toys. These activities can disrupt the healing process, irritate the surgical site, or lead to injury, including dislodgement of the stent or catheter, which is often temporarily placed post-surgery to maintain urethral patency.

Limiting such activities for a few weeks is essential to ensure proper healing and prevent complications like fistula formation or bleeding. Nurse Megan should emphasize this restriction as part of the discharge instructions to the parents.

Think of the surgical site as a freshly planted seed in soft soil. Straddle toys are like stepping on that soil, which could disturb the seed (surgical repair) before it has a chance to grow (heal).

Nurses must provide clear and practical instructions to parents to ensure the child’s safety and successful recovery after hypospadias repair.

• Advise parents to prevent the child from engaging in activities that put direct pressure on the groin area (e.g., straddling toys) for about 2–3 weeks or as directed by the surgeon.
• Teach proper catheter or stent care, if applicable, and emphasize the importance of keeping the area clean to prevent infection.
• Encourage the parents to check the surgical site daily for signs of infection, such as redness, swelling, or foul-smelling discharge, and report these to the healthcare provider.
• Instruct the parents to maintain proper hydration to prevent urinary retention and to monitor urine output.
• Reinforce the need for follow-up appointments to ensure the surgical site is healing properly and the repair is functioning as intended.

✘Incorrect answer options:

Use warm compresses to help alleviate discomfort. This is incorrect because warm compresses are not appropriate for postoperative care following hypospadias repair. Applying warmth could irritate the surgical site or increase the risk of infection.

Refrain from diapering for 1–2 weeks post-surgery. This is incorrect because diapering is necessary for young children who are not yet toilet-trained. Instead, parents should double-diaper the child or use special diapering techniques, as recommended by the surgeon, to protect the surgical site and stent.

Provide a special diet to support the healing process. This is incorrect because there is no specific dietary requirement following hypospadias repair. A normal, balanced diet appropriate for the child’s age is sufficient unless otherwise directed by the healthcare provider.

EXPLANATION

✔Correct answer:

The nurse leaves the stethoscope in the patient’s room for future use. For patients with methicillin-resistant Staphylococcus aureus (MRSA), proper infection control includes using dedicated equipment to prevent the spread of this highly contagious and antibiotic-resistant pathogen. Leaving the stethoscope in the patient’s room ensures it is used only for that patient and minimizes the risk of cross-contamination to other patients. This is a critical part of contact precautions, which are required for MRSA-positive patients.

Dedicated equipment such as stethoscopes, blood pressure cuffs, and thermometers should remain in the isolation room until the patient is discharged or until the equipment can be properly disinfected. This approach reduces the risk of spreading MRSA to healthcare workers, other patients, or shared equipment.

Think of MRSA as sticky paint. If you use a brush (the stethoscope) to paint one surface (the patient), then use the same brush on other surfaces (other patients) without cleaning or keeping it separate, the sticky paint spreads everywhere, creating a mess. By dedicating the brush to just one surface (leaving the stethoscope in the room), you keep the paint contained and prevent it from spreading to unintended places.

Nurses play a critical role in adhering to infection control measures to prevent the spread of MRSA in healthcare settings.

• Use dedicated equipment for patients under contact precautions and keep it in the room to limit cross-contamination.
• Wear appropriate personal protective equipment (PPE), such as gloves and gowns, when entering the patient’s room, and remove it before leaving.
• Disinfect hands thoroughly before and after patient care using soap and water or an alcohol-based hand sanitizer.
• If equipment must be removed from the room, clean it with an appropriate hospital-approved disinfectant to kill MRSA.
• Educate staff and visitors about the importance of adhering to contact precautions, including proper hand hygiene and use of PPE.

✘Incorrect answer options:

The nurse disinfects the stethoscope with alcohol before returning it to the exam room. This is incorrect because while disinfecting the stethoscope reduces contamination, the most appropriate action is to dedicate equipment to the MRSA patient. Shared equipment should only be used if dedicated equipment is unavailable and must be disinfected thoroughly before and after use.

The nurse uses the stethoscope for other patients under his care. This is incorrect because using the same stethoscope for other patients without proper disinfection poses a high risk of spreading MRSA. This violates contact precaution protocols.

The nurse cleans the stethoscope with water, dries it, and stores it at the nurse’s station. This is incorrect because water alone is not sufficient to kill MRSA, and storing contaminated equipment in a common area increases the risk of cross-contamination.

EXPLANATION

✔Correct answer:

Oatmeal, a glass of apple juice, dry toast, and coffee. The meal of oatmeal, apple juice, dry toast, and coffee aligns with dietary principles for managing hypertension, particularly the DASH diet (Dietary Approaches to Stop Hypertension). The DASH diet emphasizes consuming foods that are low in sodium, high in potassium, magnesium, calcium, and fiber, and minimally processed. Oatmeal is a high-fiber, heart-healthy choice that helps lower cholesterol and supports stable blood pressure. Dry toast avoids added fats like butter, and apple juice provides a source of potassium, which helps counteract the effects of sodium on blood pressure.

This meal avoids processed or high-sodium foods (e.g., bacon or ham) and high-fat dairy products (e.g., whole milk or butter), which can contribute to higher blood pressure. Coffee is acceptable in moderation, though clients with hypertension should limit excessive caffeine intake if it negatively affects their blood pressure.

Think of the DASH diet as a team of defenders protecting the blood vessels. Foods like oatmeal and fruits (apple juice) help strengthen the defense team by reducing blood pressure, while high-sodium or fatty foods weaken it.

Nurses play an essential role in helping clients understand dietary modifications for hypertension and ensuring they can apply these principles to daily meals.

• Encourage clients to limit sodium intake to less than 2,300 mg per day (or 1,500 mg for greater blood pressure control).
• Promote foods rich in potassium, such as fruits, vegetables, and whole grains, to balance sodium levels in the body.
• Advise against high-sodium processed meats (e.g., bacon, ham) and high-fat dairy (e.g., whole milk, butter).
• Support the client in choosing lean protein sources (e.g., chicken, fish, beans) and healthy fats (e.g., nuts, avocado).
• Teach clients to read food labels for hidden sodium and to use herbs and spices for flavor instead of salt.

✘Incorrect answer options:

Cornflakes with whole milk, a banana, and coffee. This is incorrect because whole milk contains saturated fat, which can contribute to cardiovascular issues, and cornflakes are often high in sodium. While the banana is a good source of potassium, the overall meal does not fully align with DASH principles.

Scrambled eggs, crispy bacon, buttered toast, and coffee. This is incorrect because bacon is high in sodium and saturated fat, and buttered toast adds unnecessary fats. While eggs can be part of a healthy diet in moderation, this meal overall is not heart-healthy.

Pancakes with ham, a glass of tomato juice, and coffee. This is incorrect because ham and tomato juice are high in sodium. Pancakes may also contain added sugar and lack whole grains, making this meal unsuitable for a hypertension-friendly diet.

EXPLANATION

✔Correct answer:

The child diagnosed with myelomeningocele. Children with myelomeningocele (a form of spina bifida) are at the highest risk for developing a latex allergy due to their frequent exposure to latex-containing medical products, such as gloves, catheters, and other medical equipment, from an early age. This repeated exposure sensitizes the immune system to latex proteins, increasing the likelihood of developing an allergy. Latex allergy in these children can result in mild reactions (e.g., skin irritation) or severe anaphylaxis, which is life-threatening.

Latex allergies occur when the immune system overreacts to proteins found in natural rubber latex. In children with myelomeningocele, the frequent use of latex products during surgical interventions, urinary catheterization, and other procedures creates repeated antigen exposure, resulting in hypersensitivity over time.

Imagine the immune system as a security guard. For children with myelomeningocele, frequent exposure to latex is like repeatedly sounding the alarm for a false intruder (latex protein). Over time, the guard becomes overly sensitive, reacting strongly even when there's no real threat.

Nurse Lily should implement precautions for children with myelomeningocele to prevent exposure to latex and minimize the risk of allergic reactions:

• Use only non-latex gloves and medical supplies for children with myelomeningocele or those at high risk for latex allergy.
• Educate the child’s caregivers about latex-free products for use at home, such as latex-free pacifiers, balloons, and toys.
• Assess for signs of latex allergy, including localized skin irritation, urticaria, respiratory symptoms, or anaphylaxis, and ensure emergency interventions (e.g., epinephrine) are readily available.
• Provide education to parents about informing all healthcare providers, schools, and childcare settings of the child’s risk for latex allergy.
• Encourage regular follow-up with an allergist if the child develops any signs of hypersensitivity.

✘Incorrect answer options:

The child diagnosed with epispadias. While children with epispadias may require surgical interventions or catheterizations, the level of latex exposure is not as high as in children with myelomeningocele. Therefore, the risk of developing a latex allergy is lower in this group.

The child diagnosed with coxa plana. Coxa plana (Legg-Calvé-Perthes disease) involves avascular necrosis of the femoral head and primarily affects the hip joint. Latex exposure is generally minimal in the management of this condition, so these children are not considered at high risk for latex allergy.

The child diagnosed with rheumatic fever. Rheumatic fever is an autoimmune condition that typically arises after a streptococcal infection. It primarily affects the heart, joints, skin, and brain. Latex exposure is not a significant factor in its treatment, so these children are not at increased risk for developing a latex allergy.

EXPLANATION

✔Correct answer:

Minimizing the secretion of pancreatic enzymes. Acute pancreatitis is an inflammatory condition of the pancreas characterized by the premature activation of digestive enzymes within the pancreas itself, leading to autodigestion, inflammation, and severe pain. The pancreas normally secretes enzymes that aid in digesting food, but in acute pancreatitis, these enzymes are overproduced or activated prematurely, worsening the inflammation. By placing the client on strict NPO (nothing by mouth) status and using an NG (nasogastric) tube to decompress the stomach, gastric stimulation is minimized, which in turn reduces the secretion of pancreatic enzymes. This approach allows the pancreas to rest and heal, thereby alleviating inflammation and preventing further damage.

Think of the pancreas as a machine that gets overheated when it’s overworked. Eating or drinking acts as a signal to turn the machine on, causing it to produce enzymes. By keeping the client on NPO status and using the NG tube to "cool down" the system, the machine (pancreas) is given time to rest and repair itself.

Nurse Carla should monitor the client closely and ensure that these interventions are carried out effectively. Considerations include the following:

• Explain to the client and family the importance of strict NPO status in promoting pancreatic rest.
• Check the placement and function of the NG tube regularly to ensure it is effectively decompressing the stomach.
• Monitor the client for signs of abdominal distension, persistent nausea, or worsening pain, which may indicate ineffective gastric decompression or complications.
• Administer IV fluids and electrolyte replacements as ordered to prevent dehydration and electrolyte imbalances caused by fluid losses and lack of oral intake.
• Monitor lab values such as serum amylase and lipase, which are elevated in pancreatitis and can help assess the client’s response to treatment.

✘Incorrect answer options:

Lowering the client’s insulin requirements. While the pancreas does play a role in insulin production, the primary concern in acute pancreatitis is the reduction of digestive enzyme secretion, not insulin management. Hyperglycemia may occur during acute pancreatitis due to pancreatic damage, but this is addressed with insulin therapy as needed, not by NPO status or an NG tube.

Suppressing the production of gastric acid. The NG tube does help to remove stomach contents, but the primary goal in acute pancreatitis is to reduce pancreatic stimulation, not directly suppress gastric acid production. Gastric acid suppression may be achieved with medications like proton pump inhibitors or H2 receptor blockers if needed, but this is a secondary consideration.

Removing the necessity for pain medication. Pain is a significant symptom of acute pancreatitis, and while resting the pancreas may help reduce pain over time, it does not eliminate the need for analgesics. Pain management typically involves medications like IV opioids to address the acute abdominal pain associated with pancreatitis.

EXPLANATION

✔Correct answer:

Use cupped hands to carry out percussion effectively. In cystic fibrosis (CF), thick mucus builds up in the lungs, impairing airway clearance and increasing the risk of infections. Postural drainage combined with percussion (chest physiotherapy) is a key intervention to help mobilize and loosen mucus so it can be expelled. Using cupped hands is the most effective technique for percussion, as the air pocket created by the cupped hand generates vibrations that travel through the chest wall and dislodge mucus from the bronchial walls. Proper technique ensures that the percussion is effective and safe without causing discomfort or bruising.

Imagine the mucus in the lungs as jelly stuck to a plate. Using cupped hands to perform percussion is like tapping the back of the plate in just the right way to loosen the jelly, making it easier to remove.

Nurse Megan should provide the following instructions and considerations when teaching postural drainage and percussion:

• Demonstrate how to position the child in various postures (e.g., head lower than the chest) to drain specific lung segments effectively.
• Instruct the mother to use cupped hands and perform rhythmic clapping on the chest wall over the appropriate lung area.
• Explain that percussion sessions should be conducted at least 1 to 2 hours before or after meals to prevent nausea or vomiting.
• Encourage performing chest physiotherapy multiple times daily (e.g., morning and evening) as prescribed by the healthcare provider.
• Stress the importance of monitoring for discomfort, bruising, or respiratory distress during therapy and stopping if any concerning symptoms arise.

✘Incorrect answer options:

Use the heel of your hand to perform percussion. The heel of the hand is not effective for chest percussion because it does not create the air pocket necessary to produce vibrations. Using the heel could also cause discomfort or injury to the child.

Reposition the child every 20 minutes during the session. While repositioning is part of postural drainage, it is not necessary to do so every 20 minutes during a single session. Instead, each position is typically held for 3 to 5 minutes to allow effective drainage of specific lung segments before changing to the next position.

Perform percussion after meals and before bedtime. Performing percussion after meals can increase the risk of vomiting or aspiration, as the child’s stomach is full. It is recommended to conduct chest physiotherapy before meals or at least 1 to 2 hours afterward. While bedtime therapy can be beneficial, timing should avoid interfering with meals or sleep.

EXPLANATION

✔Correct answer:

Split the dose into two injections and administer in both vastus lateralis muscles. The vastus lateralis muscle is the preferred injection site for infants because it is well-developed at birth, has fewer major nerves or blood vessels, and can safely accommodate small to moderate injection volumes. For infants, the maximum volume that can be safely administered in a single injection is typically 0.5 to 1 mL, depending on the size of the infant. Since the prescribed dose is 1.25 mL, it exceeds the recommended limit for a single injection. Therefore, the safest method is to split the dose into two portions (e.g., 0.625 mL each) and administer each into separate vastus lateralis muscles, one in each leg. This approach prevents local tissue damage, irritation, or complications like pain and swelling.

Think of the infant's muscle like a small sponge. If too much liquid is poured into the sponge at once, it can overflow and cause damage. By splitting the liquid into smaller portions, the sponge can absorb it safely and effectively.

Nurse Julia should follow best practices when administering injections to an infant, ensuring safety and minimizing discomfort.

• Choose the vastus lateralis as the injection site for infants under 12 months of age due to its accessibility and safety profile.
• Divide doses exceeding 1 mL into two smaller volumes and use separate sites for administration to prevent complications.
• Use a small-gauge needle (e.g., 25–27 gauge) and an appropriate length (e.g., 5/8 inch) for intramuscular injections in infants.
• Hold the infant securely to minimize movement during the injection, reducing the risk of injury.
• Monitor the injection sites for signs of redness, swelling, or tenderness, and provide parents with instructions on how to care for the injection sites at home.

✘Incorrect answer options:

Administer the full dose in a single injection into the dorsogluteal muscle. The dorsogluteal muscle is not recommended for infants due to its underdevelopment at this age and the proximity of the sciatic nerve, which increases the risk of nerve injury. Additionally, injecting 1.25 mL in a single dose exceeds the recommended volume for an infant.

Divide the dose and inject one portion in the ventrogluteal muscle and the other in the vastus lateralis muscle. While the ventrogluteal muscle is a safe injection site in older children and adults, it is less commonly used in infants because of difficulty locating the muscle and the smaller size of the site. Splitting the dose into two injections in the vastus lateralis is safer and more appropriate.

Administer the entire dose in a single injection into the ventrogluteal muscle. Although the ventrogluteal muscle is a safer option than the dorsogluteal muscle, administering 1.25 mL in a single dose still exceeds the safe volume for an infant’s small muscle capacity. Splitting the dose is essential to prevent tissue damage.

EXPLANATION

✔Correct answer:

Place a disposable diaper under the perineal opening of the cast. A hip spica cast is used to immobilize the hip and thigh in conditions such as femur fractures or developmental dysplasia of the hip. It typically covers part of the abdomen, both legs, and the pelvis, leaving an opening in the perineal area. Proper care of the perineal opening is critical to prevent skin breakdown, irritation, or cast contamination from urine and stool. Placing a disposable diaper under the perineal opening helps catch waste and absorb moisture, keeping the cast clean and dry. Additionally, a larger diaper can be placed over the outside of the cast for added protection.

Think of the spica cast as a shell with an opening for waste. The diaper acts like a carefully placed shield to prevent anything from spilling onto the shell and causing damage or irritation.

Nurse Ellie should provide the following key instructions for the parents to ensure proper care of the child in a hip spica cast:

• Use a smaller diaper tucked under the perineal opening and a larger diaper over the cast to protect the area from leaks.
• Check frequently for signs of moisture, odor, or soiling near the edges of the cast and replace the diaper promptly to keep the area clean and dry.
• Ensure good skin care around the edges of the cast by applying a barrier cream or padding to prevent irritation and pressure sores.
• Encourage repositioning every 2 hours to promote circulation and prevent pressure ulcers, with careful handling to avoid cast damage.
• Educate parents to monitor for signs of complications, such as swelling, discoloration of toes, foul odor from the cast, or excessive crying, and to contact their healthcare provider if these occur.

✘Incorrect answer options:

Keep the bed flat with a small pillow supporting the cast. Keeping the bed flat is not recommended because it can increase the risk of discomfort, pressure sores, and improper alignment. Elevating the head of the bed slightly can help with comfort and breathing, and pillows should be used to support the child’s legs, not the cast directly.

Offer crayons and coloring books to keep the child entertained. While offering activities to keep the child entertained is helpful for their emotional well-being, this is not the most critical discharge instruction. Proper cast care and hygiene take precedence over entertainment suggestions.

Focus on providing high-calorie foods to promote healing. Although adequate nutrition is essential for healing, emphasizing balanced meals with protein, vitamins, and minerals is more appropriate than focusing solely on high-calorie foods, which could lead to unnecessary weight gain in an immobilized child.

EXPLANATION

✔Correct answer:

The medication will be required for the child’s entire lifetime. Congenital hypothyroidism is a condition in which the thyroid gland is underactive or absent, leading to insufficient production of thyroid hormones that are critical for normal growth, development, and metabolism. Levothyroxine, the synthetic thyroid hormone prescribed for this condition, must be taken daily for the child's entire lifetime to replace the missing hormones and support healthy physical and cognitive development. Early and consistent treatment is essential to prevent complications such as stunted growth, developmental delays, and intellectual disabilities.

Parents should understand the importance of strict adherence to the prescribed medication regimen, as missing doses or discontinuing the medication can lead to significant health issues, especially during critical periods of growth and brain development.

Think of thyroid hormone as the fuel for a car's engine (the body). Without it, the car cannot run properly. Giving the medication daily is like filling the tank with fuel regularly to ensure the engine keeps running smoothly for a lifetime.

Nurses play a vital role in educating parents on the importance of medication adherence and monitoring the child's response to therapy.

• Reinforce that levothyroxine must be administered daily, preferably at the same time each day, to maintain stable hormone levels.
• Teach parents to crush the tablet and mix it with a small amount of water, formula, or breast milk for infants who cannot swallow pills.
• Advise against mixing the medication with soy-based formulas, as these can interfere with absorption.
• Educate parents to monitor for signs of under-treatment (e.g., lethargy, constipation, poor feeding) or over-treatment (e.g., irritability, rapid heart rate) and report these to the healthcare provider.
• Emphasize the importance of regular follow-up visits and blood tests to monitor thyroid hormone levels and adjust the dosage as the child grows.

✘Incorrect answer options:

The medication is necessary only during periods of rapid growth. This is incorrect because thyroid hormone replacement is a lifelong necessity, not just during growth spurts. Discontinuation at any stage of life can result in hypothyroid symptoms and complications.

The medication plan can include occasional drug holidays. This is incorrect because congenital hypothyroidism requires consistent daily treatment. Interruptions in therapy, even briefly, can negatively affect the child’s growth and development.

The medication should be administered every other day. This is incorrect because thyroid hormone levels need to remain stable, which requires daily dosing. Skipping days would lead to fluctuations in hormone levels, reducing the medication's effectiveness.

EXPLANATION

✔Correct answer:

Coolness and discoloration of the reimplanted digits. Coolness and discoloration of the reimplanted thumb and index finger indicate impaired blood flow, which is an emergency that requires immediate intervention to prevent tissue ischemia and necrosis. Reimplantation surgeries rely on meticulous restoration of blood vessels to ensure adequate perfusion to the reimplanted digits. Signs of impaired perfusion—such as cool, pale, cyanotic, or mottled digits—indicate possible vascular compromise, such as arterial thrombosis, venous obstruction, or inadequate anastomosis. If blood flow is not restored promptly, the reimplanted digits may not survive, and the client risks losing function or requiring further surgery, including possible amputation.

Think of the reimplanted finger as a newly planted flower. If the water supply (blood flow) to the plant is cut off, the flower will wilt (discoloration) and become cold. Immediate action is needed to restore the water supply to save the plant.

Nurse Brian should notify the physician immediately if coolness and discoloration are noted, as this finding suggests compromised circulation. Interventions include:

• Monitor and document hourly neurovascular assessments, including color, temperature, capillary refill, and pulse if accessible.
• Elevate the affected limb at heart level (not above) to promote venous return while avoiding arterial compromise.
• Ensure the surgical dressing is not too tight, as excessive compression may impair circulation.
• Administer prescribed anticoagulants or vasodilators if ordered to improve blood flow.
• Prepare the client for possible emergent intervention, such as surgical re-exploration, if vascular compromise is confirmed.

✘Incorrect answer options:

A temperature reading of 100°F. A low-grade fever (100°F) is a common postoperative finding related to the body’s inflammatory response to surgery and does not immediately indicate infection or vascular compromise. However, a fever exceeding 101°F or other signs of infection (e.g., purulent drainage, increased pain, or redness) should be reported.

Complaints of pain at the surgical site. Pain is expected after reimplantation surgery and is not necessarily an indication of a complication. Pain should be managed appropriately with prescribed analgesics. However, sudden, severe pain along with vascular symptoms may indicate ischemia and should be further investigated.

Difficulty moving the reimplanted fingers. Difficulty moving the reimplanted digits is expected in the immediate postoperative period due to swelling, surgical trauma, or nerve repair. This finding does not require urgent intervention unless accompanied by signs of vascular compromise or other complications.

EXPLANATION

✔Correct answer:

The patient is resting comfortably 30 minutes after the injection. Butorphanol (Stadol) is an opioid analgesic primarily prescribed for the management of moderate to severe pain. Its intended effect is pain relief, which allows the patient to feel more comfortable and relaxed. Observing the patient resting comfortably 30 minutes after administration is a clear indicator that the medication is achieving its desired therapeutic effect.

Opioids like butorphanol act on the central nervous system by binding to opioid receptors (mu and kappa), altering the perception of pain and providing relief. In the postoperative setting, effective pain management is essential for promoting healing, reducing stress, and improving the patient’s overall recovery experience.

Think of pain as a loud alarm in the brain. Butorphanol works like hitting the snooze button on the alarm, allowing the patient to relax and rest while the body heals.

Nurses should continuously assess the patient’s response to opioid medications to ensure they are effective and safe.

• Monitor the patient’s pain level before and after administration using a pain scale (e.g., 0–10 or faces pain scale) to evaluate effectiveness.
• Assess for potential side effects of butorphanol, such as sedation, dizziness, respiratory depression, or nausea, and intervene as needed.
• Encourage the patient to report any breakthrough pain so adjustments can be made to the pain management plan.
• Monitor vital signs closely, particularly respiratory rate, as opioids can cause respiratory depression, especially in opioid-naive patients.
• Educate the patient about the expected effects of the medication and reinforce the importance of communicating their pain levels accurately.

✘Incorrect answer options:

The patient requests additional portions of food at mealtime. This is incorrect because increased appetite is not an expected or intended effect of butorphanol. While improved comfort may indirectly lead to better food intake, this is not a primary measure of the drug's effectiveness.

The patient reports an increase in urinary output. This is incorrect because butorphanol does not directly affect urinary output. In fact, opioids may sometimes cause urinary retention rather than increased output.

The patient mentions feeling less nauseated. This is incorrect because butorphanol is not specifically used to treat nausea. Opioids, including butorphanol, can sometimes cause nausea as a side effect, so reduced nausea may be coincidental but is not the intended effect of the drug.

EXPLANATION

✔Correct answer:

The presence of nasal polyps obstructing the airway. Children with cystic fibrosis (CF) commonly develop nasal polyps, which are soft, noncancerous growths in the lining of the nasal passages or sinuses. These polyps can obstruct airflow and cause symptoms such as "snoring" sounds during breathing, nasal congestion, or difficulty breathing through the nose. Polyps occur in CF due to chronic inflammation and irritation caused by thick mucus buildup in the sinuses, a hallmark of CF.

The abnormal mucus in CF not only affects the lungs but also the upper respiratory tract, leading to sinusitis, nasal polyps, and other structural complications. Nasal polyps are especially prevalent in CF clients compared to the general population and are a significant cause of airway obstruction.

Imagine the nasal passages like tunnels that cars (air) travel through. If the tunnels have large rocks (polyps) blocking part of the way, the cars can still move, but they’ll make noise as they squeeze past the obstacles—similar to snoring sounds during breathing.

Nurses should educate caregivers about the management of nasal polyps and other associated complications of cystic fibrosis.

• Advise the caregiver to monitor for worsening nasal symptoms, such as persistent congestion or sinus infections, which may require medical evaluation.
• Discuss treatments for nasal polyps, which may include intranasal corticosteroids to reduce inflammation, nasal saline irrigation to clear mucus, or surgical removal in severe cases.
• Emphasize the importance of maintaining airway clearance through CF treatments, such as chest physiotherapy and mucolytic agents, to minimize mucus buildup.
• Educate the caregiver about regular follow-ups with an ENT specialist, as CF clients are prone to recurrent sinus and nasal issues.
• Encourage adherence to the CF treatment plan, including antibiotics when indicated, to reduce chronic inflammation and infections.

✘Incorrect answer options:

A blockage of the nasal airway due to choanal atresia. This is incorrect because choanal atresia is a congenital condition where the back of the nasal passage is blocked, typically present at birth. While it can cause noisy breathing, it is unrelated to CF and is not commonly associated with CF clients.

Structural changes caused by septal deviations. This is incorrect because septal deviations are typically caused by trauma or congenital abnormalities and are not directly associated with CF. Although they can obstruct airflow, they are not a primary cause of snoring in CF clients.

Swollen adenoids leading to airway obstruction. This is incorrect because while adenoid hypertrophy can cause snoring or nasal obstruction in children, it is not specifically associated with CF. Nasal polyps are a much more common and relevant cause of airway obstruction in CF clients.

EXPLANATION

✔Correct answer:

Offering suckers and pinwheels to enhance tongue movement. Cerebral palsy (CP) is a non-progressive neurological disorder that affects motor function, including muscle coordination, strength, and control. One common challenge in children with CP is impaired oral motor function, which can lead to difficulties with speech, swallowing, and eating. By offering suckers and pinwheels, Nurse Grace provides an engaging way to strengthen the muscles of the mouth and tongue. Sucking on a sucker or blowing on a pinwheel helps enhance oral motor control and tongue movement, which are crucial for improving speech clarity and feeding abilities. These exercises are simple, playful, and developmentally appropriate for a 4-year-old child, making them an effective preparation for further rehabilitative therapies such as speech therapy.

Think of the oral muscles as a rubber band that has become weak and floppy. Blowing on pinwheels and sucking on suckers is like gently stretching and strengthening the rubber band to make it more elastic and functional again.

Supporting rehabilitative goals in children with cerebral palsy requires a multidisciplinary approach. Nurse Grace can incorporate additional strategies to optimize the child's outcomes:

• Encourage parents and caregivers to use age-appropriate, fun activities to promote motor skills development.
• Collaborate with speech-language pathologists for targeted interventions to address oral motor delays.
• Provide adaptive feeding tools if necessary to assist with mealtimes and improve nutritional intake.
• Educate caregivers on the importance of consistency in oral exercises to ensure progress over time.
• Support the child’s emotional and psychological needs by ensuring activities are enjoyable and aligned with their developmental level.

✘Incorrect answer options:

Using an eye patch on one eye to strengthen eye muscles. Eye patching is a treatment commonly used for conditions such as strabismus or amblyopia ("lazy eye"). While some children with cerebral palsy may have vision impairments, this intervention does not address the primary rehabilitative goals of enhancing motor coordination or oral function in this context.

Playing musical tapes to assist with auditory training. While music therapy can have therapeutic benefits, auditory training is not typically a primary focus of rehabilitation for children with cerebral palsy. Rehabilitative interventions for CP more commonly target motor and communication skills.

Encouraging the use of video games to improve muscle coordination. While certain video games can help with fine motor skills, this option is not developmentally appropriate for a 4-year-old child with cerebral palsy. The child requires interventions specifically designed to target gross and fine motor impairments through direct, interactive activities.

EXPLANATION

✔Correct answer:

A rigid, boardlike abdomen. A rigid, boardlike abdomen is a critical finding that may indicate peritonitis, a potentially life-threatening complication of diverticulitis. Peritonitis occurs when a diverticulum (an inflamed or infected pouch in the colon) perforates, allowing intestinal contents to leak into the peritoneal cavity. This leakage causes widespread inflammation of the peritoneum, leading to symptoms such as severe abdominal pain, guarding, rigidity, and potentially signs of sepsis (e.g., fever, tachycardia, and hypotension). A rigid abdomen is a hallmark of peritoneal irritation and demands immediate medical intervention, such as antibiotics, fluid resuscitation, and possibly emergency surgery.

Imagine the peritoneum as a delicate balloon. If the balloon is pricked (perforation), it causes air and contents to escape, creating a tense and inflamed environment that leads to the boardlike rigidity seen in peritonitis.

Nurse James should recognize the signs of peritonitis and immediately notify the healthcare provider if this finding is present. Interventions include:

• Monitor for additional signs of peritonitis, including fever, tachycardia, hypotension, and changes in mental status.
• Prepare the client for diagnostic tests, such as an abdominal CT scan, to confirm the presence of perforation or abscess formation.
• Administer prescribed IV antibiotics to address infection and IV fluids to manage dehydration and maintain hemodynamic stability.
• Assess for signs of sepsis or shock, such as low blood pressure, rapid heart rate, or reduced urine output.
• Educate the client about the potential need for surgery, including resection of the affected bowel segment, if perforation is confirmed.

✘Incorrect answer options:

Persistent pain in the lower left quadrant. While left lower quadrant pain is the most common symptom of diverticulitis, it is not specific to complications such as perforation. Persistent pain alone may reflect inflammation or localized infection rather than a severe complication like peritonitis.

A mildly elevated temperature. A low-grade fever is a common finding in diverticulitis due to the underlying inflammation and infection. However, it is not specific to complications. A high fever combined with other symptoms (e.g., rigidity, hypotension) would be more concerning for a serious complication.

Noticeable abdominal distention. Abdominal distention may occur with diverticulitis, especially if there is an obstruction or ileus. While this is an important finding, it is less concerning than a rigid abdomen, which directly suggests peritoneal irritation and possible perforation.

EXPLANATION

✔Correct answer:

High calorie, high protein, and low fat. Clients with AIDS often experience HIV-associated wasting syndrome, characterized by significant unintentional weight loss, muscle wasting, and malnutrition. A high-calorie diet helps address increased energy demands due to hypermetabolism and chronic illness. Additionally, a high-protein diet supports muscle repair and maintenance, which is crucial in counteracting the catabolic effects of the disease. Limiting dietary fat helps prevent gastrointestinal discomfort such as diarrhea or fat malabsorption, which are common in clients with AIDS. By optimizing caloric intake and ensuring adequate protein while minimizing fat, this diet addresses weight loss while supporting tissue repair and improving overall nutritional status.

Think of the body as a house being damaged by a storm (AIDS). Protein is the building material (bricks) needed to repair the structure, while calories provide the energy for the workers to rebuild. Too much fat, like unstable materials, can slow the process by causing additional problems (e.g., GI discomfort).

Nurse Laura should ensure the client has access to dietary resources and educate them about proper nutritional practices to maintain weight and health.

• Encourage the client to consume frequent, small meals to optimize caloric and protein intake without overwhelming their digestive system.
• Recommend nutrient-dense foods, such as lean meats, eggs, legumes, and whole grains, to support calorie and protein needs.
• Advise the client to avoid high-fat or fried foods, as these may exacerbate diarrhea or gastrointestinal upset.
• Monitor for signs of malabsorption or nutrient deficiencies and collaborate with a dietitian to individualize the diet plan.
• Consider supplements, such as protein powders or meal replacement shakes, to boost caloric and protein intake if oral intake is inadequate.

✘Incorrect answer options:

High calorie, high protein, and high fat. While high-calorie and high-protein intake are appropriate, a high-fat diet is not recommended because clients with AIDS often experience fat malabsorption and diarrhea, which could worsen GI symptoms and impede nutrient absorption.

High calorie, high carbohydrate, and low protein. Although high-calorie intake is important, low protein intake would not support muscle repair or prevent muscle wasting, a significant issue in AIDS-related wasting syndrome. Protein is critical for maintaining muscle mass and immune function.

High calorie, low carbohydrate, and high fat. A low-carbohydrate, high-fat diet is not suitable because carbohydrates are a more readily available energy source, and high-fat intake could worsen GI symptoms. This diet does not effectively meet the nutritional needs of clients with AIDS who are experiencing weight loss.

EXPLANATION

✔Correct answer:

Alongside breakfast. Glucotrol XL (glipizide) is an extended-release oral sulfonylurea medication used to manage blood sugar levels in clients with type 2 diabetes mellitus. This medication works by stimulating the pancreas to release insulin and by enhancing the body's use of insulin. It is best taken alongside breakfast to ensure proper absorption and to align with the body's natural rise in blood sugar levels after meals, particularly in the morning. Taking Glucotrol XL in the morning helps prevent both hyperglycemia after breakfast and potential hypoglycemia later in the day, as the extended-release formulation provides consistent blood sugar control throughout the day.

Glucotrol XL is designed to release the active ingredient gradually, maintaining stable blood sugar levels for a prolonged period. Administering it alongside breakfast ensures it is taken with food, which minimizes the risk of gastrointestinal upset and hypoglycemia that could occur if the medication were taken on an empty stomach.

Think of Glucotrol XL as a long-lasting flashlight that you turn on in the morning to light your path for the day. If you forget to turn it on when the sun rises (breakfast), it won’t be as effective in lighting your way when you need it most.

Nurse Carla should provide clear instructions to ensure that the client understands when and how to take Glucotrol XL. The following points should be included in her education:

• Advise the client to take Glucotrol XL with breakfast or the first meal of the day.
• Educate the client about the importance of consistent mealtimes to avoid hypoglycemia.
• Instruct the client to swallow the tablet whole, without crushing or chewing, to preserve the extended-release mechanism.
• Monitor for signs of hypoglycemia, especially if the client skips meals or exercises excessively.
• Encourage the client to regularly check blood sugar levels and report any abnormal results to their healthcare provider.

✘Incorrect answer options:

Just before going to bed. Taking Glucotrol XL before bedtime is not appropriate because its primary purpose is to manage blood sugar levels during the day when the client is active and consuming meals. Taking it at night increases the risk of nocturnal hypoglycemia.

Prior to eating lunch. Taking Glucotrol XL before lunch could delay its action during the critical morning hours when blood sugar levels tend to rise after breakfast. Additionally, the timing would not align with the extended-release mechanism designed to cover an entire day.

Right after finishing dinner. Administering Glucotrol XL after dinner is incorrect as it does not align with the goal of controlling blood sugar levels during the day and early evening. It may lead to reduced daytime efficacy and increased risk of hypoglycemia during the night.

EXPLANATION

✔Correct answer:

Support the baby by the buttocks when lifting for diaper changes. Osteogenesis imperfecta (OI), commonly known as brittle bone disease, is a genetic disorder characterized by fragile bones that break easily, often with minimal or no trauma. Because the bones are extremely delicate, improper handling of the baby, such as lifting by the ankles during diaper changes, can cause fractures. Nurse Sarah should instruct the parents to support the baby by the buttocks and back when lifting, ensuring even weight distribution and minimizing strain on the fragile bones. Teaching safe handling techniques is crucial to prevent injury and ensure the baby’s safety.

OI results from a defect in collagen production, which is vital for strong bones and connective tissues. This defect leads to bones that are thin, brittle, and prone to fractures. Given this fragility, caregivers must handle the baby with extreme care to avoid accidental injuries.

Imagine the baby's bones as delicate glass figurines. If you were to handle the figurines roughly or lift them by a narrow or unsupported part, they would easily crack or break. Similarly, the baby's body needs full support to prevent fractures during handling.

Nurse Sarah should include the following in her discharge teaching to ensure the parents understand how to care for their baby safely:

• Demonstrate proper handling techniques, such as lifting the baby by supporting the back and buttocks instead of pulling on the limbs or lifting by the ankles.
• Encourage the use of padded surfaces to prevent accidental injuries during diaper changes or playtime.
• Teach parents to recognize signs of fractures, such as swelling, deformity, or crying with movement.
• Instruct parents to dress the baby in loose clothing to avoid unnecessary tugging on limbs.
• Provide information about routine follow-ups with pediatric specialists, including orthopedics and genetic counseling.

✘Incorrect answer options:

Administer daily calcium supplements to strengthen the baby’s bones. While adequate calcium intake is important for overall bone health, calcium supplements alone cannot correct the underlying collagen defect in OI. Treatment primarily focuses on fracture prevention, safe handling, and, in some cases, medications like bisphosphonates to improve bone strength.

Understand that the condition is only temporary and will resolve. OI is a lifelong genetic condition and does not resolve over time. While symptoms may vary depending on the severity, it is crucial to educate parents that this disorder requires lifelong management and preventive care.

Be aware that this condition affects only the baby’s bones. While the primary feature of OI is fragile bones, it can also affect other systems, including teeth (dentinogenesis imperfecta), hearing (due to ossicle deformities), and connective tissues. Parents need to understand that the condition can have multisystem implications and requires a multidisciplinary approach to care.

EXPLANATION

✔Correct answer:

Development of jaundice. Tacrine (Cognex) is a cholinesterase inhibitor that was one of the first medications used to treat mild to moderate dementia in conditions such as Alzheimer’s disease. While tacrine can improve cognitive symptoms by increasing the levels of acetylcholine in the brain, it is associated with significant hepatotoxicity. This can manifest as jaundice (yellowing of the skin and eyes) due to liver damage, which is a serious adverse effect. Regular monitoring of liver function tests (LFTs) is crucial while the client is taking tacrine. Elevated liver enzymes (e.g., ALT, AST) or symptoms of liver dysfunction, such as jaundice, dark urine, or upper abdominal discomfort, should prompt immediate discontinuation of the medication and notification of the healthcare provider.

Think of tacrine as a medication that helps clear "fog" in the brain (dementia symptoms), but it places a strain on the liver's "engine." If the strain becomes too much, the liver shows warning signs, like the "check engine" light coming on—jaundice is one such warning.

Nurse Emily should implement the following interventions to monitor for and prevent adverse effects of tacrine:

• Perform baseline and regular liver function tests (e.g., ALT, AST, bilirubin) as prescribed to detect early signs of hepatotoxicity.
• Assess for clinical symptoms of liver damage, such as jaundice, dark urine, fatigue, abdominal pain, or itching.
• Educate the client and family to report any signs of liver dysfunction immediately.
• Ensure the medication is taken on an empty stomach, as food may interfere with absorption.
• Monitor for other common cholinergic side effects, such as nausea, diarrhea, or dizziness, which can also occur with tacrine use.

✘Incorrect answer options:

Episodes of hypoglycemia. Hypoglycemia is not a known side effect of tacrine. It is more commonly associated with antidiabetic medications, such as insulin or sulfonylureas, and would not be expected in clients taking tacrine.

Signs of urinary retention. Urinary retention is not a typical side effect of tacrine. In fact, cholinesterase inhibitors like tacrine can increase parasympathetic activity, which might lead to increased urination rather than retention.

Complaints of tinnitus. Tinnitus (ringing in the ears) is not an adverse effect of tacrine. It is more commonly associated with medications such as aspirin or certain loop diuretics at high doses.

EXPLANATION

✔Correct answer:

Neostigmine (Prostigmine). Neostigmine is a cholinesterase inhibitor, which is the primary class of medications used in the long-term management of myasthenia gravis (MG). This medication works by inhibiting the enzyme acetylcholinesterase, which breaks down acetylcholine at the neuromuscular junction. By preventing acetylcholine breakdown, neostigmine increases the availability of acetylcholine to bind to the limited number of functional receptors in clients with MG. This enhances neuromuscular transmission and improves muscle strength, helping to alleviate the characteristic muscle weakness and fatigability seen in the condition.

Imagine acetylcholine as the key that starts a car (muscle contraction). In myasthenia gravis, there aren’t enough functional locks (receptors) for the keys. Neostigmine works like a helper that prevents the keys from being lost, making them available for reuse to start the car more effectively.

When administering neostigmine or other cholinesterase inhibitors, Nurse Olivia should take the following actions:

• Administer the medication at the prescribed time to align with the client’s meal schedule, as this maximizes muscle strength during eating and reduces the risk of aspiration.
• Monitor for signs of cholinergic crisis (overdose), which includes symptoms like excessive salivation, diarrhea, bradycardia, and muscle weakness.
• Assess the client for myasthenic crisis (underdose), characterized by worsening muscle weakness, including respiratory difficulty.
• Educate the client and caregivers about the importance of strict medication adherence to prevent symptom exacerbation.
• Encourage the client to report any sudden changes in symptoms, as dose adjustments may be required based on their response.

✘Incorrect answer options:

Atropine (atropine sulfate). Atropine is an anticholinergic medication that counteracts the effects of acetylcholine and is used to treat cholinergic crisis (overdose of cholinesterase inhibitors). It is not used for the routine management of MG, as it would worsen symptoms by further blocking neuromuscular transmission.

Etidronate (Didronel). Etidronate is a bisphosphonate used to manage conditions such as osteoporosis and Paget's disease of bone. It does not play a role in the treatment of myasthenia gravis, as it has no effect on neuromuscular transmission.

Edrophonium (Tensilon). Edrophonium is a short-acting cholinesterase inhibitor used diagnostically in the Tensilon test to confirm a diagnosis of MG by temporarily improving muscle strength. However, it is not used for long-term treatment because of its short duration of action.

EXPLANATION

✔Correct answer:

Between 3 to 4 months of age. Most babies start sleeping through the night (defined as sleeping for a stretch of 5-6 hours) between 3 to 4 months of age. By this time, their circadian rhythm begins to mature, and their stomach capacity increases, allowing them to consume enough milk or formula during the day to stay full for longer periods at night. Additionally, they develop the ability to self-soothe, which helps them transition between sleep cycles without fully waking up. It is important to note that "sleeping through the night" does not necessarily mean 8-hour stretches, but rather a consolidated period of nighttime sleep without frequent wakings.

Imagine a newborn's sleep pattern as a broken clock that needs frequent resetting (feeding and soothing). By 3 to 4 months, the clock starts working more consistently, with fewer interruptions, allowing the baby to stay "on schedule" for a longer time during the night.

Nurse Amy should provide supportive guidance to the mother and manage her expectations about her baby’s sleep patterns:

• Educate the mother about the normal variability in infant sleep patterns and that every baby develops at their own pace.
• Encourage establishing a consistent bedtime routine early, such as bathing, reading, or gentle rocking, to help the baby associate these activities with sleep.
• Discuss safe sleep practices, such as placing the baby on their back in their crib and avoiding co-sleeping to reduce the risk of sudden infant death syndrome (SIDS).
• Reassure the mother that frequent nighttime wakings are normal in the first few months and gradually decrease as the baby grows.
• Address the mother’s own sleep and mental health, emphasizing the importance of rest and support systems to manage fatigue during this demanding period.

✘Incorrect answer options:

Around 1 month of age. At 1 month, most babies still wake frequently throughout the night for feedings because their stomach capacity is small, and their sleep cycles are not yet regulated. They are unlikely to sleep for long, uninterrupted stretches.

Around 2 months of age. By 2 months, some babies may begin to sleep for longer stretches at night, but the majority still wake up every 3 to 4 hours to feed. Their sleep patterns are still maturing at this stage.

Between 5 to 6 months of age. While some babies may not sleep through the night until 5 to 6 months, many begin doing so earlier, between 3 to 4 months. Waiting until 5 to 6 months may represent a delayed timeline for the majority of infants who are already capable of longer nighttime sleep.

EXPLANATION

✔Correct answer:

In 4 weeks. Haloperidol decanoate (Haldol Decanoate) is a long-acting injectable (depot) antipsychotic used for maintenance therapy in clients with schizophrenia and other psychotic disorders. It is administered intramuscularly, and its effects typically last for about 4 weeks, making monthly injections the standard schedule for most clients. This extended dosing interval ensures consistent medication levels, improving adherence and reducing the risk of relapse due to missed doses. Nurse Rachel should instruct the client to return for the next injection in 4 weeks while emphasizing the importance of adhering to the treatment schedule.

Haloperidol decanoate is a depot formulation that slowly releases the active medication into the bloodstream over several weeks. It provides steady therapeutic levels of the drug, reducing the need for daily oral antipsychotic administration and promoting better compliance in clients who struggle with remembering or taking medications regularly.

Imagine this medication as a time-release fertilizer for a plant. Instead of needing daily watering (like oral meds), the fertilizer slowly nourishes the plant over a month. By refilling it every 4 weeks, the plant (client) stays healthy and stable without interruption.

Nurse Rachel should provide the following discharge instructions and education to ensure the client understands their treatment plan:

• Inform the client that the injection must be administered every 4 weeks to maintain stable medication levels and prevent symptom recurrence.
• Reinforce the importance of adhering to follow-up appointments and communicate the risks of missing a scheduled injection, such as the return of psychotic symptoms.
• Monitor for side effects of haloperidol, such as extrapyramidal symptoms (EPS), tardive dyskinesia, or signs of neuroleptic malignant syndrome (NMS), and advise the client to report any concerning symptoms immediately.
• Provide information about managing potential injection site reactions, such as redness or soreness, which are usually mild and self-limiting.
• Encourage open communication and collaboration with the healthcare team, including mental health providers, for holistic care and medication management.

✘Incorrect answer options:

In 1 week. Haloperidol decanoate is a long-acting formulation, and a weekly injection is not necessary. Weekly dosing would exceed the therapeutic need, increase the risk of side effects, and be inconvenient for the client.

In 2 weeks. While some depot antipsychotics may require biweekly dosing (e.g., Risperdal Consta), haloperidol decanoate is specifically designed for monthly administration. Dosing every 2 weeks would result in unnecessarily frequent injections.

In 6 weeks. The effects of haloperidol decanoate typically wear off after 4 weeks. Waiting 6 weeks between injections would leave the client without adequate medication coverage for 2 weeks, increasing the risk of relapse and symptom exacerbation.