NCLEX Practice Exam for Basic Care and Comfort

EXPLANATION

✔Correct answer:

The client’s bowel habits have not been discussed. Nurse Olivia should be concerned if the client’s bowel habits have not been discussed, as this is a critical aspect of assessing and managing chronic constipation. Understanding the client’s bowel habits, including the frequency, consistency, and timing of bowel movements, is essential for developing an effective bowel training regimen. This information helps to identify patterns and triggers that may be contributing to constipation and guides the implementation of strategies to promote regular bowel movements.

Chronic constipation can have multiple causes, including inadequate dietary fiber, insufficient fluid intake, lack of exercise, and irregular bowel habits. A bowel training regimen typically involves establishing a regular time for defecation, often after meals, when the gastrocolic reflex (the body’s natural response to eating that stimulates bowel movement) is strongest. Without understanding the client's current bowel habits, it would be challenging to tailor a regimen that works effectively for the individual.

Imagine trying to set a schedule without knowing when things usually happen. Just like planning your day around when you typically eat, sleep, or work, planning a bowel training schedule requires knowing when your body naturally wants to go to the bathroom.

Nurse Olivia should ensure that a thorough history of the client’s bowel habits is obtained. This will include details about the frequency, timing, consistency, and ease of passing stools, as well as any associated symptoms like straining or discomfort.

• Ask the client specific questions about their typical bowel routine, including how often they have bowel movements and whether they experience any difficulty or discomfort.
• Discuss the consistency of stools using the Bristol Stool Chart to provide a standardized reference.
• Identify any patterns or triggers that may influence bowel movements, such as meal timing or stress levels.
• Educate the client about the importance of responding to the urge to defecate and not ignoring it, as this can worsen constipation.
• Develop a bowel training plan based on the client’s natural bowel patterns, possibly scheduling toileting after meals to take advantage of the gastrocolic reflex.

✘Incorrect answer options:

The client’s diet includes foods that are high in bulk. A diet high in bulk, typically meaning high in fiber, is beneficial for managing constipation. Fiber adds bulk to the stool and promotes regular bowel movements by making stools softer and easier to pass. This factor does not suggest the need for more information.

The client drinks 2500-3000 ml of fluid each day. Adequate fluid intake is essential for preventing and managing constipation, as it helps to soften stools and make them easier to pass. A daily intake of 2500-3000 ml of fluid is generally appropriate, and this factor alone would not necessitate further inquiry.

The client participates in moderate exercise daily. Regular moderate exercise is beneficial for promoting bowel regularity as physical activity stimulates bowel motility. This is a positive factor and does not indicate a need for further information in the context of chronic constipation.

EXPLANATION

✔Correct answer:

The infant’s usual dietary intake.  The most crucial information Nurse Carla should gather is the infant’s usual dietary intake. Iron deficiency anemia in infants is often linked to inadequate dietary iron intake, particularly if the infant is consuming a diet low in iron-rich foods or is receiving excessive amounts of cow’s milk, which is low in iron and can interfere with iron absorption. Infants who are not consuming sufficient iron-fortified formula, iron-rich solid foods, or who transitioned to cow’s milk before 12 months of age are at increased risk for developing iron deficiency anemia.

Iron deficiency anemia occurs when there is insufficient iron to produce hemoglobin, the oxygen-carrying component of red blood cells. Infants have high iron requirements due to rapid growth and development, and their diet must provide adequate iron to meet these needs. Prolonged iron deficiency can lead to developmental delays and other complications, making it essential to assess and address dietary intake.

Imagine trying to build a house (healthy body) but not having enough bricks (iron) to make the walls (hemoglobin). Without enough bricks, the house won’t be strong. Similarly, without enough iron, the body can’t produce enough healthy red blood cells.

Nurse Carla should assess the infant's diet for adequate iron sources and educate the parents on the importance of including iron-rich foods, such as iron-fortified cereals, pureed meats, and legumes. If the diet is lacking, dietary adjustments or iron supplementation may be necessary.

• Ask about the types and amounts of foods and liquids the infant consumes daily, including the use of formula, breast milk, cow’s milk, and solid foods.
• Educate parents on the signs of iron deficiency anemia, such as pallor, irritability, and fatigue.
• Discuss appropriate dietary sources of iron and ways to improve iron absorption, such as combining iron-rich foods with vitamin C-rich foods.
• Monitor the infant’s growth and development closely, and consider blood tests to measure hemoglobin and serum ferritin levels if iron deficiency is suspected.
• Evaluate the need for iron supplementation in consultation with the pediatrician, especially if dietary intake is insufficient.

✘Incorrect answer options:

The family’s sociocultural, economic, and educational background. While this information can provide context and may influence dietary practices, it is not as directly related to the immediate assessment of iron deficiency anemia as the infant’s dietary intake. Sociocultural factors might contribute to dietary choices, but the actual diet is the most critical factor.

Any signs of blood in the infant’s stools. Although blood in the stool could indicate gastrointestinal bleeding, which might contribute to anemia, it is not the most common cause of iron deficiency anemia in infants. The focus should first be on dietary intake before considering other less common causes.

A history of maternal anemia during pregnancy. While maternal anemia can increase the risk of anemia in the infant, especially in the early months of life, by 11 months, the infant's diet plays a more crucial role in maintaining adequate iron levels. Thus, current dietary intake is more relevant to assess at this stage.

EXPLANATION

✔Correct answer:

"Children can develop bone demineralization more quickly than adults during immobility."  The best statement capturing the impact of immobility on children is that "Children can develop bone demineralization more quickly than adults during immobility." Prolonged immobility in children can lead to rapid bone demineralization, putting them at risk for conditions such as osteoporosis or fractures. This occurs because bones in children are still growing and require regular weight-bearing activities to maintain their strength and density. Without these activities, bone resorption can outpace bone formation, leading to a decrease in bone mass.

In children, bone growth and remodeling are ongoing processes that are highly dependent on physical activity. Weight-bearing exercises stimulate osteoblastic activity, which is crucial for bone formation and maintaining bone density. During periods of immobility, the lack of mechanical stress on bones leads to increased bone resorption, where calcium is released from the bones into the bloodstream, leading to a decrease in bone density.

Think of bones like muscles—they get stronger the more they are used. If a child stops using their bones (due to immobility), it's like not exercising muscles—they start to weaken and lose strength

quickly.

Nurse Sarah should monitor Jacob for signs of bone weakness or pain, particularly in the weight-bearing bones like the legs. Early mobilization and physical therapy should be encouraged as soon as it is safe to do so, to help counteract the effects of immobility on bone density. Additionally, ensuring adequate calcium and vitamin D intake is important to support bone health during periods of limited mobility.

• Encourage early mobilization and physical activity as soon as medically appropriate to stimulate bone strength and prevent demineralization.
• Monitor for signs of bone pain, weakness, or fractures, which may indicate significant bone demineralization.
• Ensure that Jacob's diet includes adequate calcium and vitamin D to support bone health during immobility.
• Work closely with physical therapists to develop an appropriate exercise regimen that is safe for Jacob's recovery phase.

✘Incorrect answer options:

"Children are less likely to experience complications from immobility compared to adults." This statement is inaccurate. Children are vulnerable to many of the same complications of immobility as adults, such as muscle atrophy, joint contractures, and bone demineralization, and they may actually experience these complications more quickly due to their growth processes.

"Prolonged immobility in children primarily affects their psychological well-being." While immobility can indeed impact a child's psychological well-being, such as causing feelings of isolation or depression, the physical effects, especially on bone and muscle health, are significant and must not be overlooked.

"The effects of immobility in children are usually reversible with physical therapy." While physical therapy can help reverse some of the effects of immobility, not all consequences may be fully reversible, especially if bone demineralization or muscle wasting has progressed significantly. Prevention of these effects through early intervention is preferable to solely relying on reversibility.

EXPLANATION

✔Correct answer:

Elevate the head of the bed by 4-6 inches.  Elevating the head of the bed by 4-6 inches is one of the most effective non-pharmacological interventions to reduce symptoms of gastroesophageal reflux disease (GERD). This position helps prevent stomach acid from flowing back into the esophagus, particularly during sleep, when reflux symptoms can be more pronounced. Gravity assists in keeping the acid in the stomach, reducing the likelihood of acid reflux and the discomfort associated with it.

GERD occurs when the lower esophageal sphincter (LES) weakens or relaxes inappropriately, allowing stomach acid to escape into the esophagus. Elevating the head of the bed reduces the risk of acid reflux by using gravity to keep the acid in the stomach and away from the esophagus. This simple intervention can significantly decrease nighttime reflux symptoms and improve sleep quality.

Imagine your stomach is like a cup filled with liquid (acid). If you tilt the cup, the liquid will stay at the bottom, but if you lay the cup flat, the liquid can spill out. Elevating your head is like tilting the cup, keeping the liquid (acid) where it belongs.

Nurse Sarah should instruct the patient on how to properly elevate the head of the bed using blocks, wedges, or a specially designed wedge pillow. Additionally, she should discuss the importance of maintaining this position consistently, particularly after meals and during sleep, to maximize its effectiveness.

• Educate the patient on using bed risers or a wedge pillow to achieve the correct elevation.
• Reinforce the importance of avoiding lying flat after meals to prevent reflux.
• Advise the patient to avoid eating large meals, especially late in the evening, to reduce the risk of nighttime reflux.
• Encourage the patient to maintain a healthy weight, as obesity can exacerbate GERD symptoms.

✘Incorrect answer options:

Lie down immediately after meals. Lying down immediately after eating is contraindicated in GERD patients because it increases the likelihood of acid reflux. When a person lies flat, gravity no longer helps keep stomach contents in the stomach, making it easier for acid to move back up into the esophagus.

Increase fluid intake right before going to bed. Increasing fluid intake before bed can increase the volume of stomach contents, which may worsen reflux symptoms at night. It's generally recommended to avoid large meals and excessive fluids before lying down.

Wear a tight girdle. Wearing a tight girdle or any tight clothing around the abdomen can increase intra-abdominal pressure, pushing stomach contents up into the esophagus and exacerbating GERD symptoms. Loose-fitting clothing is recommended for individuals with GERD to minimize pressure on the abdomen.

EXPLANATION

✔Correct answer:

A 79-year-old malnourished client who is on bed rest.  This client is at the greatest risk for developing pressure ulcers due to a combination of factors: malnutrition and immobility. Malnutrition impairs the body's ability to maintain healthy skin, which increases the susceptibility to skin breakdown. When combined with being on bed rest, where constant pressure on certain areas of the body can lead to reduced blood flow and ischemia, the risk of developing pressure ulcers is significantly heightened.

Pressure ulcers, also known as decubitus ulcers or bedsores, occur when prolonged pressure on the skin reduces blood flow to the area, leading to tissue ischemia and necrosis. The sacrum, heels, and hips are common sites for these ulcers in bedridden patients. Malnutrition further exacerbates this risk as it impairs wound healing and decreases the integrity of the skin, making it more vulnerable to pressure-induced damage.

Think of the skin as a cushion. If the cushion (skin) is thin and worn out due to malnutrition, and someone sits on it constantly (bed rest), the cushion can wear down faster and develop holes (pressure ulcers).

It is essential to regularly reposition the client to alleviate pressure on vulnerable areas, ensure adequate nutritional intake to support skin integrity, and implement skincare routines to keep the skin clean and dry.

• Regular repositioning at least every two hours to relieve pressure.
• Assess the skin daily for early signs of pressure ulcers, such as redness or non-blanchable areas.
• Ensure that the client receives adequate protein, calories, and hydration to support skin health.
• Utilize pressure-relieving devices, such as specialized mattresses or cushions.
• Educate the client and caregivers about the importance of skin care and nutrition in preventing pressure ulcers.

✘Incorrect answer options:

An obese client who relies on a wheelchair. While obesity and prolonged sitting in a wheelchair can contribute to pressure ulcer risk, this client is not as high-risk as the malnourished, bedbound client. The increased body fat may provide some cushioning, and the ability to shift weight or reposition oneself in a wheelchair can reduce the duration of pressure on any one area.

An incontinent client who has experienced three episodes of diarrhea. Incontinence and diarrhea can contribute to skin breakdown, especially in the perineal area, but this client’s risk is not as high as the malnourished and bedbound client. Prompt skin care and use of barrier creams can help mitigate the risk of ulcers in this client.

An 80-year-old ambulatory client with diabetes. Although diabetes can impair wound healing and increase the risk of ulcers, an ambulatory client is less likely to develop pressure ulcers because mobility helps maintain good circulation and prevents prolonged pressure on one area. However, they should still be monitored for other complications related to diabetes, such as neuropathy or foot ulcers.

EXPLANATION

✔Correct answer:

To enhance circulation and improve muscle tone.  The primary advantage of therapeutic massages is to enhance circulation and improve muscle tone. Therapeutic massage increases blood flow to the massaged areas, which helps in delivering oxygen and nutrients to tissues while removing waste products. This improved circulation can also reduce muscle tension, relieve pain, and improve overall muscle tone and flexibility. Regular massages can contribute to maintaining the health of muscles and tissues, which is particularly beneficial for individuals recovering from injuries or those with chronic musculoskeletal conditions.

Therapeutic massage stimulates the circulatory system by mechanically encouraging blood flow through the tissues. Increased circulation enhances the delivery of oxygen and nutrients necessary for muscle repair and function, and helps in the removal of metabolic waste products, which can accumulate and contribute to muscle soreness and fatigue. The mechanical stimulation of muscles during a massage can also prevent muscle atrophy and promote relaxation, further improving muscle tone and overall physical well-being.

Think of your muscles like a garden that needs watering. Massage acts like a gentle rain that not only waters the garden but also helps remove any weeds (waste products) that are hindering the growth (healing and muscle tone) of your plants (muscles).

Nurse Jessica should educate the patient about the benefits of therapeutic massage for improving circulation, especially in individuals who may be at risk for poor circulation due to conditions like sedentary lifestyles, chronic pain, or musculoskeletal disorders. She should also advise on the appropriate frequency and type of massage therapy suited to the patient’s specific health needs.

• Educate the patient on how regular massage can complement other therapies, especially for muscle and joint health.
• Discuss any potential contraindications to massage therapy, such as certain cardiovascular conditions or recent surgeries.
• Ensure the patient understands the importance of hydration before and after a massage to help flush out toxins and improve circulation.
• Encourage the patient to report any discomfort or unusual symptoms during or after the massage, as these may indicate the need for adjustments to the therapy.

✘Incorrect answer options:

To reduce fluid retention in a person with swollen legs. While massage can help with lymphatic drainage and may reduce minor swelling, it is not the primary treatment for fluid retention or significant edema, especially in conditions like heart failure or severe lymphedema. Medical interventions are typically required to manage fluid retention effectively.

To provide relief for someone with duodenal ulcers. Therapeutic massage is not indicated for treating duodenal ulcers. While massage can reduce stress, which may indirectly benefit ulcer healing, it does not directly address the ulcer or its symptoms. Duodenal ulcers require medical treatment, typically involving medications to reduce stomach acid and heal the ulcer.

To promote healing of damaged tissue in a diabetic patient. While massage can improve circulation, which may support healing, it is not the primary therapy for healing damaged tissues in diabetic patients. Special care must be taken with massage in diabetic patients, particularly if they have neuropathy or poor wound healing, as aggressive massage could potentially cause harm. Wound care and blood sugar control are more critical in the healing of damaged tissues in diabetic patients.

EXPLANATION

✔Correct answer:

Decrease. Mr. Harris's pain tolerance is likely to decrease due to both his age and his cancer condition. As people age, they often experience changes in the nervous system, including a decline in the number of nerve fibers and changes in pain perception. These factors can lead to an increased sensitivity to pain, meaning that the elderly may perceive pain more intensely than younger individuals. Additionally, cancer and its associated treatments (e.g., chemotherapy, radiation) can cause chronic pain and exacerbate pain sensitivity, further lowering the patient's pain tolerance.

In elderly patients, age-related changes such as decreased skin thickness, reduced muscle mass, and altered pain signaling pathways can contribute to a heightened perception of pain. Cancer-related pain, often due to tumor growth, nerve compression, or treatment side effects, can further overwhelm the body's pain regulation mechanisms, leading to a decreased ability to tolerate pain.

Imagine pain tolerance like a dam holding back a river (pain signals). In a younger person, the dam is strong and can hold back more water (pain). But with age and illness, the dam may weaken, allowing more water to spill over, making even small increases in water level (pain stimuli) feel overwhelming.

Nurses should take extra care to assess pain regularly in elderly cancer patients and should not assume that a lack of complaints means an absence of pain. It's important to use appropriate pain assessment tools, especially those designed for older adults, and to manage pain proactively using pharmacological and non-pharmacological approaches.

• Conduct regular pain assessments using tools appropriate for elderly patients, such as the Numeric Rating Scale or the Faces Pain Scale-Revised.
• Consider both pharmacologic interventions (e.g., analgesics, adjuvant therapies) and non-pharmacologic interventions (e.g., massage, heat therapy, relaxation techniques) to manage pain effectively.
• Educate Mr. Harris and his family about the importance of reporting pain early and accurately to ensure timely and effective pain management.
• Monitor for side effects of pain medications, especially in elderly patients who may be more susceptible to adverse effects such as sedation or gastrointestinal issues.
• Collaborate with a multidisciplinary team, including palliative care, to create a comprehensive pain management plan tailored to Mr. Harris's needs.

✘Incorrect answer options:

Remain unchanged: It is unlikely that Mr. Harris's pain tolerance would remain unchanged given the physiological changes associated with aging and the impact of his cancer condition.

Increase: Pain tolerance generally does not increase with age, especially in the presence of chronic conditions like cancer. Elderly patients are more likely to experience decreased pain tolerance due to these factors.

Have no impact on pain tolerance: Both aging and cancer are significant factors that can influence pain perception and tolerance. It is not accurate to say they would have no impact.

EXPLANATION

✔Correct answer:

Chocolate.  Patients with gastroesophageal reflux disease (GERD) should avoid chocolate because it can exacerbate heartburn symptoms. Chocolate contains both caffeine and theobromine, which can relax the lower esophageal sphincter (LES). When the LES relaxes, stomach acid is more likely to reflux into the esophagus, causing the characteristic burning sensation of heartburn. Additionally, chocolate is high in fat, which can further slow gastric emptying and increase the risk of acid reflux.

The LES normally acts as a barrier, preventing the contents of the stomach from refluxing into the esophagus. Foods like chocolate can weaken or relax the LES, making it easier for acid to move from the stomach into the esophagus, which leads to irritation and the symptoms of GERD.

Think of the LES as a door that should stay closed to keep everything inside. Chocolate is like a slippery handle that makes the door (LES) harder to keep shut, allowing contents (acid) to escape and cause discomfort.

Nurse Lisa should educate the patient about the types of foods that can trigger GERD symptoms and suggest alternatives. It's important to help the patient identify their specific triggers and make dietary adjustments that will help reduce the frequency and severity of heartburn.

• Encourage the patient to keep a food diary to track foods that trigger symptoms.
• Advise on the importance of smaller, more frequent meals to avoid overfilling the stomach.
• Suggest low-fat options and foods that are less likely to relax the LES.
• Recommend other lifestyle modifications such as avoiding eating late at night and elevating the head of the bed.

✘Incorrect answer options:

Lettuce is a non-acidic, low-fat vegetable that is generally safe for people with GERD to eat. It is unlikely to trigger heartburn and is often included in a GERD-friendly diet.

Eggs are generally considered safe for most people with GERD, especially when prepared without added fat, such as poached or boiled. However, some individuals might be sensitive to eggs, particularly when fried or cooked with butter, which can trigger symptoms.

Butterscotch is a sweet treat, but it doesn't typically contain ingredients that are known to exacerbate GERD symptoms like chocolate does. However, it is still high in sugar and fat, which some GERD patients may need to limit.

EXPLANATION

✔Correct answer:

Stiffness of the right ankle joint.  Stiffness of the right ankle joint is a significant complaint that should alert Nurse Jamie to a potential complication of immobility, specifically joint contractures. When a patient is bedridden for an extended period, joints can become stiff due to lack of movement, leading to the formation of contractures. Contractures occur when the muscles, tendons, and ligaments surrounding a joint become shortened, resulting in decreased flexibility and range of motion. If not addressed, this can lead to permanent deformity and loss of function.

Immobilization affects multiple systems, including the musculoskeletal system, where disuse leads to muscle atrophy, joint stiffness, and the potential development of contractures. The synovial fluid that lubricates joints may decrease, and the joint capsule may tighten, causing stiffness and pain. Regular movement and physical therapy are essential to prevent these complications.

Think of joints like hinges on a door. If the door isn't opened regularly, the hinges can get rusty and stiff, making it hard to move. Similarly, if a joint isn't moved, it can become stiff and difficult to move.

To prevent and manage joint stiffness and potential contractures, it’s important to implement range-of-motion (ROM) exercises, reposition the patient frequently, and encourage as much movement as the patient can tolerate.

• Perform passive or active range-of-motion exercises several times a day, depending on the patient’s ability.
• Reposition the patient every 1-2 hours to prevent pressure ulcers and promote circulation.
• Consider the use of splints or braces to maintain proper joint alignment and prevent contractures.
• Encourage physical therapy consultations to develop a tailored exercise regimen.
• Assess for pain and administer analgesics if necessary before exercises to improve patient participation.

✘Incorrect answer options:

Soreness of the gums. While soreness of the gums may be a concern, particularly related to oral hygiene or nutritional deficiencies, it is not a primary complication of immobility. This issue would be more directly related to poor oral care or systemic conditions affecting oral health rather than immobility.

Short-term memory loss. Short-term memory loss could be related to various factors, including aging, neurological conditions, or medications, but it is not a direct complication of immobility. Memory loss may warrant further investigation, but it is not as directly related to immobility as joint stiffness is.

Decreased appetite. Decreased appetite can be a side effect of immobility, often due to a decrease in metabolic rate and reduced physical activity, but it is not as immediately concerning as joint stiffness when considering the complications of immobility. While decreased appetite should be addressed to ensure proper nutrition, it does not have the same immediate implications for joint function and mobility as stiffness does.

EXPLANATION

✔Correct answer:

Acknowledge and accept his report of pain.  The first step in assessing Mr. Jones's pain is to acknowledge and accept his report of pain. Pain is a subjective experience, and the patient's report is the most reliable indicator of pain. By acknowledging and validating the patient's experience, Nurse Laura establishes trust and shows empathy, which are crucial for effective pain management. This approach ensures that the patient's pain is taken seriously and that appropriate interventions will be considered.

Pain is a complex, subjective phenomenon that involves sensory, emotional, and cognitive components. The perception of pain can vary widely among individuals, and factors such as past experiences, emotions, and cultural background can influence how pain is experienced and reported. Acknowledging the patient's report of pain is essential in the holistic assessment and management of pain.

Think of pain assessment as listening to someone who tells you they’re cold. You wouldn’t question their feeling but rather acknowledge it and then find out more details to help them feel comfortable. Similarly, the first step in pain management is to acknowledge the patient’s pain before moving forward with further assessment.

After acknowledging the pain, Nurse Laura should proceed with a comprehensive pain assessment, including asking about the pain’s location, intensity, quality, duration, and factors that alleviate or worsen it. This information is vital to developing an effective pain management plan tailored to Mr. Jones's needs.

• Acknowledge Mr. Jones's report of pain as a valid and important part of the assessment.
• Proceed with obtaining a detailed description of the pain, including location, intensity, quality, and associated factors.
• Assess the impact of pain on Mr. Jones's daily activities, mood, and overall quality of life.
• Document the findings accurately to guide the development of a personalized pain management plan.

✘Incorrect answer options:

Ask the client to identify their coping strategies. While understanding how the patient copes with pain is important, it is not the first step in pain assessment. Coping strategies should be explored after acknowledging the patient's pain and obtaining a comprehensive description of the pain experience.

Obtain a description of the pain’s location and intensity. Gathering information about the pain’s location and intensity is crucial, but it should come after acknowledging and accepting the patient's report of pain. This approach ensures that the patient feels heard and respected, which is essential for building trust.

Assess the current status of the client’s pain. Assessing the current status of the pain is part of a thorough pain assessment, but it follows the initial acknowledgment and validation of the patient’s pain experience. The first step should always be to validate the patient's experience before diving into the specifics of the pain.

EXPLANATION

✔Correct answer:

Portal hypertension.  The primary cause of esophageal varices is portal hypertension, which occurs when there is increased pressure in the portal venous system, often due to liver cirrhosis. This increased pressure causes blood to be redirected to collateral veins, including those in the esophagus, leading to their dilation and the formation of varices. These varices are abnormally enlarged veins that are prone to rupture, potentially leading to life-threatening bleeding.

Portal hypertension typically results from liver cirrhosis, where scar tissue impedes blood flow through the liver, causing blood to back up into the portal vein. As the pressure builds, blood seeks alternative pathways to return to the systemic circulation, often through veins in the esophagus, which are not equipped to handle such high pressures. This leads to the dilation of these veins, forming varices that are fragile and susceptible to bleeding.

Imagine a highway (the portal vein) that's suddenly blocked by heavy traffic (liver cirrhosis). Cars (blood) start to detour through smaller side streets (esophageal veins), which weren't built to handle this much traffic. The side streets become crowded and damaged (varices), and a small accident (rupture) can cause a major traffic jam (bleeding).

Nurses should monitor patients with esophageal varices for signs of gastrointestinal bleeding, such as hematemesis (vomiting blood) or melena (black, tarry stools). They should also educate patients on avoiding activities that could increase abdominal pressure, such as heavy lifting, which could precipitate a variceal bleed. Additionally, nurses play a key role in managing and preventing complications associated with portal hypertension.

• Monitor for signs of bleeding, such as hematemesis or melena.
• Educate the patient about avoiding activities that increase abdominal pressure to reduce the risk of variceal rupture.
• Administer medications as prescribed to manage portal hypertension, such as beta-blockers, which can reduce the risk of bleeding.
• Prepare for potential interventions, such as endoscopic banding or sclerotherapy, if bleeding occurs.

✘Incorrect answer options:

Ascites and edema. While ascites (accumulation of fluid in the abdomen) and edema are common complications of portal hypertension, they do not directly cause esophageal varices. These conditions result from fluid shifts due to low albumin levels and increased pressure in the portal system, but they are not the primary factor in the development of varices.

Systemic hypertension. Systemic hypertension, or high blood pressure in the body's general circulation, is not directly related to the development of esophageal varices. Portal hypertension, not systemic hypertension, is the key factor in this condition.

Dilated veins and varicosities. Dilated veins and varicosities describe the outcome of the process but not the underlying cause. These are the result of portal hypertension, which leads to the development of varices. Thus, while descriptive, this option does not address the root cause.

EXPLANATION

✔Correct answer:

Helping the patient with early ambulation using a walker. Early ambulation is crucial in the recovery process after hip fracture repair, especially in elderly patients. Assisting the patient with early ambulation using a walker helps to promote circulation, reduce the risk of complications such as deep vein thrombosis (DVT) and pneumonia, improve muscle strength, and enhance joint mobility. Early ambulation also contributes to the patient’s psychological well-being by encouraging independence and confidence in mobility.

After hip surgery, immobilization can lead to complications such as muscle atrophy, joint stiffness, and reduced cardiovascular function. Early ambulation helps to combat these issues by promoting blood flow, maintaining muscle strength, and improving joint flexibility, all of which are essential for a successful recovery. The use of a walker provides the necessary support and stability to ensure the patient can ambulate safely without placing excessive strain on the healing hip.

Think of the patient’s muscles and joints like a bicycle that hasn’t been used in a while. If the bike isn’t taken out for a ride, the chain may rust, and the tires may go flat. Similarly, if the patient doesn’t start moving early, their muscles could weaken, and their joints could become stiff, making recovery more difficult.

Nurse Emily should ensure that the patient is safely assisted during ambulation, using proper body mechanics to prevent falls. It is also important to monitor the patient’s pain level and vital signs during and after ambulation to ensure that the patient is tolerating the activity well.

• Provide clear instructions and support while assisting the patient with the walker.
• Assess the patient’s pain level before ambulation and administer pain relief as needed.
• Encourage the patient to take slow, steady steps and to use the walker for balance and stability.
• Monitor for signs of fatigue, dizziness, or discomfort, and allow for rest periods as necessary.
• Ensure that the environment is safe for ambulation, with clear pathways and no obstacles.

✘Incorrect answer options:

Encouraging the patient to stay in bed as much as possible to avoid pain. Prolonged bed rest can lead to complications such as muscle atrophy, joint stiffness, and an increased risk of DVT and pulmonary issues. While it is important to manage pain, immobilization can hinder recovery and prolong the patient’s hospital stay.

Assisting the patient in performing passive range-of-motion exercises. Passive range-of-motion exercises are helpful for maintaining joint mobility, but they do not provide the benefits of weight-bearing activity like early ambulation does. Active mobilization and weight-bearing exercises are key to regaining functional mobility after hip surgery.

Applying cold compresses to the surgical site to reduce inflammation. Cold compresses can be effective in reducing postoperative pain and inflammation, but this intervention alone does not help the patient begin resuming her activities. Early ambulation is more critical for recovery and functional outcomes.

EXPLANATION

✔Correct answer:

It provides the patient with control over their pain management. The primary benefit of using cutaneous stimulation for pain relief is that it empowers the patient by providing them with a sense of control over their pain management. Cutaneous stimulation methods, such as massage, transcutaneous electrical nerve stimulation (TENS), heat therapy, and cold therapy, allow patients to actively participate in managing their pain. This can be particularly beneficial for individuals with chronic pain, as it gives them an immediate and tangible way to alleviate discomfort without relying solely on medications.

Cutaneous stimulation works by activating the body's natural pain-relief mechanisms. Techniques like TENS or massage stimulate nerve fibers in the skin, which can block pain signals from reaching the brain by activating the "gate control theory" of pain. According to this theory, non-painful input (like the sensation from a massage) can close the nerve "gates" to painful input, thereby reducing the perception of pain.

Think of cutaneous stimulation as a volume control on a radio. When you increase the volume of soothing music (stimulation), it drowns out the background noise (pain), giving you control over what you hear (feel).

Nurse Karen should educate Mrs. Lewis on the different types of cutaneous stimulation techniques, how to properly use them, and how they can be incorporated into her daily routine. It's also important to emphasize that while these methods can be effective, they may work best when combined with other pain management strategies.

• Demonstrate how to use devices like TENS units or apply heat/cold packs safely and effectively.
• Discuss the importance of regular use and consistency in applying these methods to achieve optimal pain relief.
• Encourage Mrs. Lewis to keep a pain diary to track which techniques are most effective for her.
• Educate Mrs. Lewis on when to avoid certain techniques, such as avoiding heat on inflamed or infected areas.
• Assess for any contraindications or precautions, such as skin sensitivity or cardiovascular issues, that might affect the choice of cutaneous stimulation methods.

✘Incorrect answer options:

It is more cost-effective: While some cutaneous stimulation methods may be cost-effective, this is not the primary benefit. The main advantage is the ability to provide patients with control over their pain management.

It limits movement and decreases pain: Cutaneous stimulation does not necessarily limit movement; in fact, it often encourages movement by reducing pain. Limiting movement is not a desired outcome in most cases of chronic pain management.

It enables the family to assist in the patient's care at home: Although family involvement in pain management is beneficial, the primary benefit of cutaneous stimulation is that it gives the patient direct control over their pain, rather than relying on others.

EXPLANATION

✔Correct answer:

Engage in weight-bearing exercises.  The most crucial advice Nurse Julia should give Mrs. Thompson regarding exercise is to engage in weight-bearing exercises. Weight-bearing exercises, such as walking, jogging, dancing, or stair climbing, are essential in managing osteoporosis because they help build and maintain bone density. These exercises work by forcing the body to work against gravity, stimulating the bones to become stronger and denser, which is particularly important in preventing further bone loss in individuals with osteoporosis.

Osteoporosis is characterized by a decrease in bone mass and density, leading to fragile bones that are more prone to fractures. Weight-bearing exercises promote bone remodeling, where bone formation exceeds bone resorption, thereby helping to maintain or even increase bone density. This process is particularly beneficial for patients with osteoporosis as it can slow the progression of the disease and reduce the risk of fractures.

Think of bones like a bank account. Just as depositing money into a savings account helps it grow, doing weight-bearing exercises "deposits" strength into your bones, making them stronger and more resilient over time.

Nurse Julia should instruct Mrs. Thompson on appropriate types of weight-bearing exercises and ensure she understands how to perform them safely to avoid injury. It is also important to emphasize the consistency of exercise as a key factor in achieving and maintaining bone health.

• Educate Mrs. Thompson on different weight-bearing exercises that she can incorporate into her daily routine, such as walking, dancing, or using resistance bands.
• Encourage Mrs. Thompson to start slowly and gradually increase the intensity and duration of her exercise routine, depending on her physical capabilities and overall health.
• Stress the importance of consistency, advising her to aim for at least 30 minutes of weight-bearing exercise most days of the week.
• Ensure Mrs. Thompson understands how to exercise safely, including avoiding high-impact activities that could increase her risk of falls and fractures.
• Recommend a combination of weight-bearing, strength-training, and balance exercises to maximize the benefits for her bone health.

✘Incorrect answer options:

Exercise to achieve weight loss. While maintaining a healthy weight is important, the primary goal of exercise in the context of osteoporosis is to strengthen bones and improve balance, rather than focusing on weight loss. In fact, being underweight is a risk factor for osteoporosis and could increase the risk of fractures.

Avoid exercises that could increase the risk of fractures. While it is important to avoid exercises that may be too strenuous or risky, this advice alone is not as crucial as emphasizing the importance of engaging in weight-bearing exercises. Safe exercise practices should be encouraged, but the focus should be on activities that enhance bone density.

Exercise to build muscle strength and protect bones. Building muscle strength is beneficial, but the key focus for osteoporosis should be on weight-bearing exercises that directly improve bone density. Strength training is important but should be part of a broader exercise regimen that includes weight-bearing activities to effectively manage osteoporosis.

EXPLANATION

✔Correct answer:

Vegetable soup made with vegetable stock, carrots, celery, and legumes, served with toasted oat bread.  This option is the best choice for a low-fat, high-fiber diet. The vegetable soup made with vegetable stock and a variety of vegetables, particularly legumes, is low in fat and high in dietary fiber. Legumes (such as beans and lentils) are an excellent source of fiber, which is beneficial for digestive health and can help in managing cholesterol levels. The toasted oat bread also provides additional dietary fiber while being low in fat, making this meal an ideal choice for following a low-fat, high-fiber diet.

A low-fat, high-fiber diet is often recommended for individuals who need to manage their weight, reduce cholesterol levels, and improve overall cardiovascular health. Fiber helps in digestion, promotes satiety, and assists in regulating blood sugar levels. Low-fat foods help to reduce the intake of unhealthy fats, particularly saturated and trans fats, which are associated with cardiovascular disease.

Think of fiber like a broom that sweeps through your digestive system, helping to keep things moving smoothly. And low-fat foods are like choosing to put light, healthy fuel in your car instead of heavy, greasy oil, ensuring it runs cleanly and efficiently.

Nurses should reinforce the importance of selecting foods that are naturally high in fiber, such as vegetables, fruits, whole grains, and legumes, while also being mindful of fat content. Educating patients on reading food labels to check for fiber content and fat levels is crucial for successful adherence to dietary guidelines.

• Encourage patients to increase their intake of whole grains, legumes, fruits, and vegetables to meet fiber requirements.
• Advise patients to choose cooking methods that minimize fat, such as steaming, grilling, or baking, rather than frying.
• Discuss the importance of hydration, as a high-fiber diet requires adequate fluid intake to prevent constipation.
• Educate patients on avoiding foods high in saturated and trans fats, such as processed snacks, fried foods, and fatty meats.
• Support patients in making gradual changes to their diet to improve compliance and sustain long-term healthy eating habits.

✘Incorrect answer options:

Tuna salad sandwich on whole wheat bread. While this option includes whole wheat bread, which is high in fiber, the tuna salad may contain mayonnaise, which adds fat. Additionally, tuna salad is often made with higher-fat ingredients, making this option less ideal for a low-fat diet.

Chef’s salad with hard-boiled eggs and fat-free dressing. Although this salad includes fat-free dressing, which aligns with the low-fat guideline, the salad likely includes other ingredients such as cheese, processed meats (like ham or bacon), and eggs, which can add fat. Additionally, chef’s salads often lack the high fiber content found in foods like legumes or whole grains.

Broiled chicken stuffed with chopped apples and walnuts. While the chicken is broiled, which is a low-fat cooking method, the dish includes walnuts, which are high in fat. Although they contain healthy fats, the overall fat content is still higher than desired for a low-fat diet. Moreover, the dish does not emphasize fiber-rich foods as much as the correct option does.

EXPLANATION

✔Correct answer:

Holding the cane in her left hand, Ms. Karen moves the cane forward first, then her right leg, and finally her left leg.  Ms. Karen is using the cane correctly by holding it in her left hand, which is the side opposite to her weak side (right-sided weakness). The correct technique involves moving the cane forward first to provide support, followed by the weak leg (right leg), and then the stronger leg (left leg) to complete the step. This method ensures that the cane is providing stability and support when the weaker leg is in motion, reducing the risk of falls.

After a stroke, weakness on one side of the body (hemiparesis) can significantly impair mobility. When using a cane, the cane should be held on the side opposite to the affected limb. This is because the cane takes over some of the weight-bearing responsibility, compensating for the weaker leg. By moving the cane forward first, it acts as an additional point of support, helping to stabilize the patient as they move their weaker leg forward.

Imagine walking with a friend who is weaker on one side. If you’re supporting them, you would stay on their stronger side, so your support hand (like the cane) is available to help as they step forward with their weaker side. This setup ensures they don’t fall over while moving.

Nurses should ensure that the patient is educated on the proper use of a cane to enhance safety and prevent falls. This includes teaching the correct sequence of movements and ensuring the cane is adjusted to the correct height.

• Assess the cane's height to ensure it is adjusted correctly—usually, the handle should be at the level of the wrist when the arm is relaxed at the side.
• Instruct the patient to always move the cane and the weaker leg together to ensure balance and support.
• Reinforce the importance of looking ahead while walking, rather than down at the feet, to maintain proper posture and prevent falls.
• Encourage the patient to practice cane use under supervision until confident in their ability to use it safely.
• Evaluate the patient’s environment to ensure it is free of hazards that might cause tripping or falling.

✘Incorrect answer options:

Holding the cane in her right hand, Ms. Karen moves the cane forward first, then her left leg, and finally her right leg. This option is incorrect because the cane should be held in the hand opposite to the weaker side (left hand, in this case). Holding the cane in the right hand, which is the same side as the weakness, would not provide optimal support when the weaker leg is in motion.

Holding the cane in her right hand, Ms. Karen moves the cane and her right leg forward together, then moves her left leg forward. This technique is also incorrect because, while it includes moving the cane and the weaker leg together, the cane should be held in the left hand (opposite to the weaker side) to ensure proper balance and support.

Holding the cane in her left hand, Ms. Karen moves the cane and her left leg forward together, then moves her right leg forward. This option is incorrect because the cane should be moved along with the weaker leg (right leg), not the stronger leg (left leg). Moving the cane with the stronger leg does not offer the needed support when the weaker leg is in motion.

EXPLANATION

✔Correct answer:

3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange.  The most suitable meal plan for Mr. Davis, who is on a sodium-restricted diet following a myocardial infarction, is 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange. This meal is low in sodium and includes fresh, unprocessed foods, which are ideal for managing sodium intake. Fresh turkey (as long as it's not processed or seasoned with salt), sweet potatoes, and green beans are naturally low in sodium. Additionally, the inclusion of fresh fruits like oranges adds essential nutrients without contributing to sodium levels.

Sodium intake is closely related to blood pressure regulation and fluid balance in the body. Excess sodium can lead to fluid retention, increasing the workload on the heart, which is particularly dangerous for someone recovering from a myocardial infarction. A diet low in sodium helps prevent hypertension and reduces the risk of further cardiovascular events by minimizing the strain on the heart.

Think of sodium as a sponge that absorbs water in your body. If you take in too much sodium, it's like adding more sponges, which can lead to too much water being retained, making it harder for your heart to work. Choosing foods with less sodium is like removing those extra sponges, making it easier on your heart.

Nurse Linda should educate Mr. Davis on how to read food labels to identify sodium content and encourage the selection of fresh, unprocessed foods. Additionally, she should discuss alternative seasoning options like herbs and spices to enhance flavor without adding sodium.

• Instruct Mr. Davis to choose fresh, unprocessed meats and vegetables over canned or processed options to reduce sodium intake.
• Educate Mr. Davis on how to read nutrition labels, focusing on sodium content, to make informed dietary choices.
• Suggest the use of herbs, spices, and lemon juice as alternatives to salt for seasoning food.
• Encourage regular monitoring of blood pressure and weight as part of managing cardiovascular health post-myocardial infarction.

✘Incorrect answer options:

3 oz. broiled fish, 1 baked potato, ½ cup canned beets, 1 orange, and milk. Although this option includes fresh fish and a baked potato, the inclusion of canned beets is problematic. Canned vegetables often contain added sodium as a preservative, making them less suitable for a sodium-restricted diet.

3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple. Canned salmon, although nutritious, often contains added sodium, which is not ideal for someone on a sodium-restricted diet. Fresh or frozen salmon would be a better choice.

A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice. Bologna is a highly processed meat that is typically high in sodium, making it unsuitable for a sodium-restricted diet. Additionally, processed meats like bologna can contribute to poor cardiovascular outcomes.

EXPLANATION

✔Correct answer:

Replace the TPN solution every 24 hours. The TPN solution should be replaced every 24 hours to reduce the risk of infection, which is one of the most significant concerns associated with TPN therapy. TPN solutions are rich in glucose and other nutrients, creating an ideal environment for bacterial growth if not handled properly. Replacing the solution every 24 hours helps to ensure that the solution remains sterile and minimizes the risk of contamination and subsequent bloodstream infections.

TPN is delivered via a central venous catheter, which provides direct access to the bloodstream. The nutrient-rich composition of TPN makes it a potential medium for bacterial proliferation if the solution is not handled with strict aseptic techniques. By replacing the TPN solution every 24 hours, the risk of introducing bacteria into the bloodstream and causing a serious infection like sepsis is significantly reduced.

Think of TPN as a container of fresh food. Just as you wouldn’t leave food out for more than a day because it could spoil and make you sick, the TPN solution needs to be changed every 24 hours to prevent it from “spoiling” and causing an infection.

Nurse Kelly should monitor the TPN administration closely, including regular assessments of the catheter site for signs of infection, checking blood glucose levels, and ensuring that all aspects of TPN administration adhere to strict aseptic techniques. The TPN solution should be prepared by a pharmacy under sterile conditions and hung by the nurse within 24 hours of preparation.

• Ensure that the TPN solution is replaced every 24 hours and that the administration set (tubing) is changed according to the facility's protocol.
• Monitor the central venous catheter site for signs of infection, such as redness, swelling, or discharge.
• Regularly check the patient's blood glucose levels, as TPN solutions are high in glucose and can cause hyperglycemia.
• Maintain strict aseptic technique when handling the TPN solution, tubing, and central line to prevent contamination.
• Monitor the patient’s electrolyte levels and adjust the TPN formulation as necessary to maintain balanced nutrition and prevent complications.

✘Incorrect answer options:

Hold all medications while TPN is being administered. Medications do not need to be held during TPN administration. However, it is crucial that no medications are infused through the TPN line unless they are specifically compatible with the TPN solution, to avoid potential interactions or contamination.

Flush the TPN line with water before starting the nutritional infusion. The TPN line should not be flushed with water before starting the infusion. Instead, it should be flushed with a compatible solution, typically saline, to maintain line patency and prevent mixing incompatible substances with the TPN solution, which could lead to precipitation or infection.

Maintain the patient on strict bed rest throughout TPN therapy. While patients receiving TPN may have limited mobility due to their underlying condition, strict bed rest is not a requirement of TPN therapy itself. In fact, encouraging mobility as tolerated is generally beneficial for preventing complications like deep vein thrombosis (DVT).

EXPLANATION

✔Correct answer:

"Take lactase enzyme supplements before consuming dairy products."  Lactase enzyme supplements can be taken before consuming dairy products to help digest lactose, the sugar found in milk and other dairy foods. These supplements provide the enzyme that individuals with lactose intolerance lack, thereby reducing or preventing symptoms such as bloating, gas, and diarrhea. This allows Sarah to enjoy dairy products without discomfort and helps ensure she maintains an adequate intake of nutrients such as calcium and vitamin D.

Lactose intolerance occurs when the body does not produce enough lactase, an enzyme required to break down lactose into glucose and galactose, which can then be absorbed in the small intestine. Without sufficient lactase, lactose remains undigested and is fermented by bacteria in the colon, leading to symptoms of intolerance. By taking lactase supplements, Sarah can better digest lactose and avoid the gastrointestinal symptoms associated with lactose intolerance.

Think of lactase supplements as providing the "key" to unlock lactose, making it easier for the body to digest dairy products without causing any unwanted symptoms.

Nurse Emily should educate Sarah on the proper use of lactase supplements, including timing and dosage. She should also advise Sarah on reading food labels to identify lactose-containing products and consider integrating lactose-free dairy options into her diet.

• Instruct Sarah to take lactase supplements immediately before consuming dairy products to enhance lactose digestion.
• Advise Sarah to experiment with different brands or types of lactase supplements to find one that works best for her.
• Encourage Sarah to choose lactose-free or reduced-lactose dairy products as an alternative to traditional dairy options.
• Discuss the importance of maintaining adequate calcium and vitamin D intake, especially if dairy consumption is reduced.

✘Incorrect answer options:

"You should drink at least one glass of milk each day to build tolerance." This advice is not appropriate because consuming milk daily without lactase supplementation can cause significant discomfort in individuals with lactose intolerance. While some people might develop a slight tolerance over time, it's generally better to manage symptoms by limiting lactose intake or using lactase supplements rather than risking discomfort.

"Include more whole grains and leafy greens to compensate for reduced dairy intake." While whole grains and leafy greens are healthy and can provide some calcium, they are not direct substitutes for the high calcium content found in dairy products. Additionally, this option does not address the immediate management of lactose intolerance symptoms.

"Switch to full-fat dairy products to reduce lactose content." Full-fat dairy products still contain lactose, and the fat content does not significantly alter the lactose content. Moreover, higher fat intake can have other dietary implications and may not necessarily be beneficial for managing lactose intolerance.

EXPLANATION

✔Correct answer:

Elevate the head of the bed to at least 30 degrees.  Elevating the head of the bed to at least 30 degrees is the most crucial nursing action before administering a bolus enteral feeding, especially in a client with major head trauma. This position helps reduce the risk of aspiration, which is a significant concern in patients receiving enteral feedings. Aspiration can lead to pneumonia and other serious complications, particularly in patients who may have impaired gag or swallow reflexes due to neurological injury.

Patients with head trauma are at an increased risk of aspiration due to potential alterations in their level of consciousness and neuromuscular function. By elevating the head of the bed, gravity helps keep the stomach contents from regurgitating into the esophagus and potentially being aspirated into the lungs. This precaution is essential for preventing aspiration pneumonia, which can be life-threatening in critically ill patients.

Think of the stomach as a bottle of liquid. If you lay the bottle flat, the liquid can easily spill out when the cap is loosened. But if you keep the bottle upright, the liquid stays inside even if you remove the cap. Similarly, elevating the head of the bed helps keep stomach contents in place, reducing the risk of them spilling into the lungs.

In addition to elevating the head of the bed, Nurse Kim should ensure that the patient remains in this position for at least 30 minutes after the feeding to further reduce the risk of aspiration. It’s also important to monitor the patient’s respiratory status and watch for any signs of distress during and after the feeding.

• Ensure the head of the bed is elevated to at least 30 degrees before and during the feeding.
• Keep the head of the bed elevated for at least 30 minutes after the feeding to minimize aspiration risk.
• Monitor the patient’s respiratory status, including breathing pattern and oxygen saturation.
• Assess for signs of aspiration, such as coughing, choking, or changes in respiratory status.
• Check tube placement and residual volume before administering the feeding to ensure safety.

✘Incorrect answer options:

Flush the feeding tube with water to ensure patency. While flushing the tube with water is important to ensure patency and clear the tube of any obstructions, it is not the most crucial action in preventing complications like aspiration, especially in a patient with head trauma. Ensuring the head of the bed is elevated takes precedence to prevent a potentially life-threatening situation.

Check the client's blood glucose level. Monitoring blood glucose is important for patients receiving enteral nutrition, particularly if they have diabetes or are at risk for hyperglycemia. However, it is not the most critical immediate action before administering a bolus feeding in this scenario.

Warm the feeding solution to room temperature. Warming the feeding solution can help improve patient comfort and reduce gastrointestinal discomfort. However, it is not as crucial as elevating the head of the bed to prevent aspiration, which is a more immediate and serious concern.