NCLEX RN EXAM PACK SET 11 75 QUESTIONS WITH RATIONALES & ANSWERS LATEST UPDATED 2023_2024, Exams of Nursing

Download NCLEX RN EXAM PACK SET 11 75 QUESTIONS WITH RATIONALES & ANSWERS LATEST UPDATED 2023_2024 and more Exams Nursing in PDF only on Docsity! 1 Correct Answer: A. Elevated serum calcium The parathyroid glands regulate the calcium level in the blood. In hyperparathyroidism, the serum calcium level will be elevated. A normal PTH in the presence of hypercalcemia is considered inappropriate and still consistent with PTH-dependent hypercalcemia. PTH levels should be very low in those patients with PTH-independent hypercalcemia. A comprehensive clinical evaluation complemented by routine laboratory and radiologic studies should be sufficient to establish a diagnosis of primary hyperparathyroidism in a patient with persistent hypercalcemia and an elevated serum level of parathyroid hormone. o Option B: Parathyroid hormone levels may be high or normal but not low. Patients with primary hyperparathyroidism and other causes of PTH- dependent hypercalcemia often have frankly elevated levels of PTH, while some will have values that fall within the reference range for the general population. It is uncommon for clinically occult malignancies to cause hypercalcemia. Most patients with malignancy- 1. 1. Question A patient is admitted to the hospital with a diagnosis of primaryhyperparathyroidism. A nurse checking the patient‟s lab resultswould expect which of the following changes in laboratory findings? o A. Elevated serum calcium o B. Low serum parathyroid hormone (PTH) o C. Elevated serum vitamin D o D. Low urine calcium 2 • 2. Question A patient with Addison‟s disease asks a nurse for nutrition anddiet advice. Which of the following diet modifications is not recommended? o A. A diet high in grains. o B. A diet with adequate caloric intake. o C. A high protein diet. o D. A restricted sodium diet. o Option A: Addison‟s disease is a rare condition. It develops when the adrenal glands, which are located above the kidneys, do not make enough of certain hormones. These hormones are important for normal body function. They help the body cope with stress, hold salt and water, and maintain blood pressure. The Correct Answer: D. A restricted sodium diet. A patient with Addison‟s disease requires normal dietary sodium to prevent excess fluid loss. Do not reduce salt in the diet. The client may need to add extra salt to his food during hot and humid weather or after exercise to replace salt lost through sweating. Do not use salt substitutes. associated hypercalcemia are known to have cancer, or cancer is readily detectable on initial evaluation, and PTH levels will be suppressed. o Option C: Parathyroid hormone levels may be high or normal but not low. The body will lower the level of vitamin D in an attempt to lower calcium. o Option D: Urine calcium may be elevated, with calcium spilling over from elevated serum levels. This may cause renal stones. A review of previous medical records can often be of significant value in establishing the cause of hypercalcemia. Most patients with hyperparathyroidism have persistent or intermittent hypercalcemia for many years before a definitive diagnosis is established. 5 o A. Bowel perforation o B. Viral gastroenteritis o C. Colon cancer o D. Diverticulitis Correct Answer: A. Bowel perforation Bowel perforation is the most serious complication of fiberoptic colonoscopy. Important signs include progressive abdominal pain,fever, chills, and tachycardia, which indicate advancing peritonitis. Bowel perforation results from insult or injury to the mucosa of the bowel wall resulting from a violation of the closed system. This exposes the structures within the peritoneal cavity to gastrointestinal contents. Patients presenting with abdominal pain and distension, especially in the appropriate historical setting, must be evaluated for this entity as delayed diagnosis can be life-threatening due to the risk of developing infections such as peritonitis. o Option B: Several different viruses including rotavirus, norovirus, adenovirus, and astroviruses account for most cases of acute viral gastroenteritis. Most are transmitted via the fecal-oral route, includingcontaminated food and water. Transmission has also been shown to occur via fomites, vomitus, and possibly airborne methods. Norovirus is more resistant to chlorine and ethanol inactivation than other viruses.Acute gastroenteritis is defined by loose or watery diarrhea that consists of 3 or more bowel movements in a day. Other symptoms may include nausea, vomiting, fever, or abdominal pain o Option C: Colon cancer does not cause these symptoms. Tumor location on clinical presentation canbe separated on left-sided with more changes in bowelhabits and hematochezia, and right-sided with obscured anemia impacting on late stage at diagnosis.The provider should perform a thorough physical examination for signs of ascites, hepatomegaly, and lymphadenopathy. 6 o Option A: PTT tests the function of all clotting factors except factor VII (tissue factor) and factor XIII (fibrin stabilizing factor). PTT is commonly used in clinical practice to monitor patient response to unfractionated heparin infusion, to target therapeutic anticoagulation, and as part of a “coagulation panel” to help elucidate causes of bleeding or clotting disorders. Correct Answer: A, B, & C Prothrombin time, partial thromboplastin time, and platelet count are all included in coagulation studies. • 5. Question A patient is admitted to the same day surgery unit for liverbiopsy. Which of the following laboratory tests assesses coagulation? Select all that apply. o A. Partial thromboplastin time o B. Prothrombin time o C. Platelet count o D. Hemoglobin o E. Complete Blood Count o F. White Blood Cell Count o Option D: Diverticulitis may cause pain, fever, and chills, but is far less serious than perforation and peritonitis. Acute diverticulitis is inflammation due to micro-perforation of a diverticulum. The diverticulum is a sac-like protrusion of the colon wall. Diverticulitis can present in about 10% to 25% of patients with diverticulosis. Diet appears to play a significant role. Low fiber, high fat, and red meat diets may increase the risk for development of diverticulosis and possible diverticulitis. Obesity and smoking are known to increase the potential for both diverticulitis and diverticular bleeding. 7 o Option B: Prothrombin time (PT) is one of several blood tests routinely used in clinical practice to evaluate the coagulation status of patients. More specifically, PT is used to evaluate the extrinsic and common pathways of coagulation, which would detectdeficiencies of factors II, V, VII, and X, and low fibrinogen concentrations. o Option C: Clinicians can monitor the function of platelets by evaluating the bleeding time, which evaluates the time between breaking the vasculatureand formation of an effective platelet plug. This timemay be elevated in conditions like uremia, in which platelet count is normal but demonstrates impaired function. o Option D: A hemoglobin test measures the levels of hemoglobin in the blood. Hemoglobin is a protein in the red blood cells that carries oxygen from the lungsto the rest of the body. Hemoglobin variant testing measures by percentage, the relative hemoglobin types present in erythrocytes. This testing allows for the detection of hemoglobin variants and thalassemicdisorders. o Option E: A complete blood count (CBC) is a blood test used to evaluate the overall health and detect a wide range of disorders, including anemia, infection and leukemia. A complete blood count test measuresseveral components and features of the blood, including red blood cells, white blood cells, hemoglobin, hematocrit, and platelets. o Option F: A white blood cell (WBC) count is a test thatmeasures the number of white blood cells in the body. Of note, if a subtype of white blood cells seems to be elevated based on the differential, the actual value of the type of white blood cells should be calculated by multiplying the percentage listed on the differential bythe total number of white blood cells. Question • 6. A patient on the cardiac telemetry unit unexpectedly goes into ventricular fibrillation. The advanced cardiac life support team prepares to defibrillate. Which of the following choices indicatesthe correct placement of the conductive gel pads? 10 Correct Answer: A. Irrigate the eye repeatedly with normal saline solution. Emergency treatment following a chemical splash to the eye includes immediate irrigation with normal saline. The irrigation should be continued for at least 10 minutes. Immediate irrigation with copious amounts of an isotonic solution is the mainstay of treatment for chemical burns. Never use any substance to • 8. Question A patient arrives in the emergency department and reports splashing concentrated household cleaner in his eye. Which ofthe following nursing actions is a priority? o A. Irrigate the eye repeatedly with normal salinesolution. o B. Place fluorescein drops in the eye. o C. Patch the eye. o D. Test visual acuity. should be calculated after listening for at least two minutes. Normal bowel sounds are low-pitched and gurgling, and the rate is normally 2-5/min. o Option B: Intestinal obstruction causes the sounds to intensify as the normal flow is blocked by the obstruction. Absent bowel sounds may indicate paralytic ileus and hyperactive rushes (borborygmi) are usually present in small bowel obstruction and sometimes may be auscultated in lactose intolerance o Option C: The swishing and buzzing sound of turbulent blood flow may be heard in the abdomen in the presence of abdominal aortic aneurysm, for example, and should always be considered abnormal. The diaphragm should be placed above the umbilicus to listen for an aortic bruit and then moved 2 cm above and lateral to the umbilicus to listen for a renal bruit. The presence of the former indicates an abdominal aortic aneurysm and the latter indicates renal artery atherosclerosis. 11 Correct Answer: D. Temperature of 101.8 F (38.7 C). neutralize chemical exposure as the exothermic reaction can leadto secondary thermal injuries. Irrigation should continue until the pH of the eye is between 7.0 to 7.4 and remains within this rangefor at least 30 minutes after the irrigation has been discontinued. o Option B: Fluorescein drops are used to check for scratches on the cornea due to their fluorescent properties and are not part of the initial care of a chemical splash. A topical anesthetic such as tetracaine can be applied directly to the eye, or 10 mL of 1% lidocaine can be added to a liter of irrigating fluid, taking care not to reach a toxic dose if copious irrigation is required. o Option C: Patching the eye would not remove the chemical. Severe burns may require upwards of ten liters of irrigation. Irrigation should be gentle, and care should be taken to avoid direct irrigation to the cornea to prevent further injury. Use of a commercial irrigation lens such as a Morgan lens may be helpful. o Option D: Following irrigation, visual acuity will be assessed. Ocular burns, particularly any chemical burns with corneal clouding or abrasions, should have prompt ophthalmology evaluation. Topical antibiotic ointment and possibly topical steroids may be prescribed for both chemical and thermal burns, but topical steroids should only be prescribed in consultation with an ophthalmologist. • 9. Question A nurse is caring for a patient who has had hip replacement. Thenurse should be most concerned about which of the following findings? o A. Complaints of pain during repositioning. o B. Scant bloody discharge on the surgical dressing. o C. Complaints of pain following physical therapy. o D. Temperature of 101.8 F (38.7 C). 12 Post-surgical nursing assessment after hip replacement should beprincipally concerned with the risk of neurovascular complicationsand the development of infection. A temperature of 101.8 F (38.7 C) postoperatively is higher than the low grade that is to be expected and should raise concern. The THA postoperative wound complication spectrum ranges from superficial surgical infections (SSIs) such as cellulitis, superficial dehiscence, and/or delayed wound healing, to deep infections resulting in full- thickness necrosis. Deep infections result in returns to the operating room for irrigation, debridement (incision and drainage)and depending on the timing of the infection, may require explanation of THA components. o Option A: Joint replacement surgery relieves the painand stiffness of arthritis for most people. Some people may still have some symptoms of arthritis. For most people, surgery usually provides enough relief of symptoms for most people. Loosening of the new jointover time can cause pain, and sometimes another surgery is needed to fix the problem. o Option B: A small amount of bloody drainage on the surgical dressing is a result of normal healing. normal to lose blood during and after hip or knee replacementsurgery. Some people need a blood transfusion during surgery or during their recovery period in the hospital.Some surgeries require you to donate blood before surgery. Much of the bleeding during surgery comes from the bone that has been cut. A bruise may occur ifblood collects around the new joint or under the skin after surgery. o Option C: Some pain following physical therapy is to be expected and can be managed with analgesics. As in its counterpart TKA procedure, aseptic loosening is the result of a confluence of steps involving particulatedebris formation, prosthesis micromotion, and macrophage-activated osteolysis. Treatment requires serial imaging and radiographs and/or CT imaging for preoperative planning. Persistent pain requires revision THA surgery. • 10. Question A child is admitted to the hospital with an uncontrolled seizure disorder. The admitting physician writes orders for actions to be 15 Correct Answer: B, C, D & E Polycythemia vera is a condition in which the bone marrow produces too many red blood cells. This causes an increase in hematocrit and viscosity of the blood. Patients can experience headaches, dizziness, tinnitus, and visual disturbances. Cardiovascular effects include increased blood pressure and delayed clotting time. o Option A: Weight loss is not a manifestation of polycythemia vera. Weight loss adversely impacts • 12. Question A patient is admitted to the hospital with suspected polycythemiavera. Which of the following symptoms is consistent with the diagnosis? Select all that apply. o A. Weight loss o B. Increased clotting time o C. Hypertension o D. Headaches o E. Tinnitus o Option C: First-line treatment includes glucocorticoids and intravenous immune globulins; these agents inhibit autoantibody production and platelet degradation. Second-line treatment includes rituximab, immunosuppressive drugs, and splenectomy. Third-line agents are thrombopoietin receptor agonists, which stimulate platelet production. o Option D: Iron supplementation should be taken without food to increase absorption. Low gastric pH facilitates iron absorption. Rapid response to treatment is often seen in 14 days. It is manifested by the rise in hemoglobin levels. Iron supplementation is needed for at least three months to replenish tissue iron stores and should proceed for at least a month even after hemoglobin has returned to normal levels. 16 survival in cancer patients. JAK2 myeloproliferative neoplasms (MPN) upregulate tumor necrosis factor alpha (TNF-?), interleukin-6 (IL-6), and IL-8 and inducedecreased leptin levels leading to weight loss. The impact of weight loss in PV patients receiving best supportive care (i.e. frontline hydroxyurea [HU] therapy, phlebotomy) on overall survival (OS) is largely unknown. o Option B: Bleeding and thrombotic complications areeach observed in 1% of patients. Bleeding events can include epistaxis, gum bleeding, and gastrointestinal (GI) bleeding. Thrombotic events can include deep venous thrombosis (DVT), pulmonary embolism (PE), Budd-Chiari syndrome, splanchnic vein thrombosis, stroke, and arterial thrombosis. o Option C: The overproduction of red blood cells and high hematocrit levels associated with polycythemia vera can contribute to systemic hypertension; high hematocrit levels have been found to interfere with the vasodilatory effects of nitric oxide. The treatment of polycythemia, which can involve phlebotomy, can alleviate the systemic hypertension, as well as the physiological consequences of having a high red bloodcell count. o Option D: As polycythemia vera is a myeloproliferative syndrome, it is based on an autonomic increase in the proliferation of all hematopoietic cells–mostly of erythropoiesis. An increase in blood viscosity induces disturbed microcirculation, resulting in headaches with clinicalsymptoms. o Option E: Symptoms are related to hyperviscosity and thrombosis, impairing oxygen delivery. Physical complaints can include fatigue, headache, dizziness,tinnitus, vision changes, insomnia, claudication, pruritus, gastritis, and early satiety. • 13. Question A nurse is caring for a patient with a platelet count of 20,000/microliter. Which of the following is an importantintervention? 17 o A. Observe for evidence of spontaneous bleeding. o B. Limit visitors to family only. o C. Give aspirin in case of headaches. o D. Impose immune precautions. Correct Answer: A. Observe for evidence of spontaneousbleeding. Platelet counts under 30,000/microliter may cause spontaneous petechiae and bruising, particularly in the extremities. When thecount falls below 15,000, spontaneous bleeding into the brain and internal organs may occur. The blood clotting cascade is an integral system requiring intrinsic and extrinsic factors. Derangements in any factors can affect clotting ability. These laboratory tests provide important information about the patient‟scoagulation status and bleeding potential. The specific laboratory values to be monitored will depend on the patient‟s specific clinical condition. o Option B: There is no reason to limit visitors as long as any physical trauma is prevented. Educate the patient and family members about signs of bleeding that need to be reported to a health care provider. Early evaluation and treatment of bleeding by a healthcare provider reduce the risk for complications from blood loss. o Option C: Headaches may be a sign and should be watched for. Aspirin disables platelets and should never be used in the presence of thrombocytopenia. Educate the patient about over-the-counter drugs andavoid products that contain aspirin or NSAIDs such as ibuprofen and naproxen. These drugs not only decrease normal platelet aggregation but also decrease the integrity of gastric mucosa through inhibition of cyclooxygenase (COX)-1 inhibitor and therefore increase the risk for gastrointestinal bleeding. o Option D: Thrombocytopenia does not compromiseimmunity. Educate the at-risk patient about precautionary measures to prevent tissue trauma or 20 o D. Minimize conversation with the patient. Correct Answer: B. Change gloves immediately after use. The neutropenic patient is at risk of infection. Changing gloves immediately after use protects patients from contamination with organisms picked up onhospital surfaces. This contamination canhave serious consequences for an immunocompromised patient.Wear gloves when providing direct care; perform hand hygiene after properly disposing gloves. o Option A: Changing the respiratory mask is desirable,but not nearly as urgent as changing gloves. Wear personal protective equipment (PPE) properly. Use masks, goggles, face shields to protect the mucous membranes of your eyes, mouth, and nose during procedures and in direct-care activities (e.g., suctioning secretions) that may generate splashes or sprays of blood, body fluids, secretions, and excretions. o Option C: Place the patient in protective isolation if the patient is at high risk of infection. Protective isolation is set when the WBC indicates neutropenia. Provide surgical masks to visitors who are coughing and provide rationale to enforce usage. Instruct visitors to cover mouth and nose (by using the elbowsto cover) during coughing or sneezing; use of tissues to contain respiratory secretions with immediate disposal to a no-touch receptacle; perform hand hygiene afterward. o Option D: Minimizing conversations are not necessaryand may cause nursing staff to miss changes in the patient‟s symptoms or condition. Educating visitors on the importance of preventing droplet transmission from themselves to others reduces the risk of infection. • 16. Question A nurse is counseling patients at a health clinic on the importanceof immunizations. Which of the following information is the most accurate regarding immunizations? 21 o A. All infectious diseases can be prevented with properimmunization. o B. Immunizations provide natural immunity fromdisease. o C. Immunizations are risk-free and should be universallyadministered. o D. Immunization provides acquired immunity fromsome specific diseases. Correct Answer: D. Immunization provides acquiredimmunity from some specific diseases. Immunization is available for the prevention of some, but not all, specific diseases. This type of immunity is “acquired” by causing antibodies to form in response to a specific pathogen. Live vaccines are more effective than killed vaccines because they retain more antigens of the microbes. However, toxoids, includingthose that cause tetanus and diphtheria, are the most effective bacterial vaccines of all because they are based on inactivated exotoxins that stimulate strong antibody production. Subunit vaccines, including hepatitis B, meningococcal, and Haemophilus influenzae B vaccines are effective when conjugated to carrier proteins such as tetanus toxoid. o Option A: Immunizations can prevent some, but not all, infectious diseases. The current immunizations protect against diphtheria, tetanus, pertussis, poliomyelitis, measles, mumps, rubella, pneumococcalpneumonia, smallpox, sepsis, meningitis, hepatitis B, varicella-zoster, tuberculosis, cholera, diarrhea causedby rotavirus, salmonellosis, and dengue. o Option B: Natural immunity is present at birth because the infant acquires maternal antibodies. Innate (natural) immunity is so named because it is present at birth and does not have to be learned through exposure to an invader. It thus provides an immediate response to foreign invaders. However, itscomponents treat all foreign invaders in much the same way. 22 o Option A: The physician will see the patient as soon as possible with the above actions underway. Often when anaphylaxis is diagnosed co-treatment is initiated with steroids, antihistamines, inhaled bronchodilators, and vasopressors. Glucagon can also be used if indicated. These agents can assist in Correct Answer: B. Maintain a patent airway. The patient may be experiencing an anaphylactic reaction. Airway management is paramount. Thoroughly examine the patient for airway patency or any indications of an impending loss of airway. Perioral edema, stridor, and angioedema are very high risk, and obtaining a definitive airway is imperative. Delay may reduce the chances of successful intubation as continued swelling occurs, increasing the risk for a surgical airway. • 17. Question A patient is brought to the emergency department after a bee sting. The family reports a history of severe allergic reaction, andthe patient appears to have some oral swelling. Which of the following is the most urgent nursing action? o A. Consult a physician. o B. Maintain a patent airway. o C. Administer epinephrine subcutaneously. o D. Administer diphenhydramine (Benadryl) orally. o Option C: Immunization, like all medication, cannot be risk-free and should be considered based on the risk of the disease in question. Most vaccines have adverse reactions as any drug or medication. For example, BCG vaccination may provoke fever, vomiting, hematuria, lymphadenitis, and redness at the site of injection. HiB vaccine has few adverse reactions, and none of them are dangerous. These reactions include redness, warmth, swelling, and fever over 101 degrees F. A rare and lethal adverse reaction secondary to vaccination is the Guillain-Barre syndrome. 25 A patient at a mental health clinic is taking Haldol (haloperidol) for treatment of schizophrenia. She calls the clinic to report abnormal movements of her face and tongue. The nurse concludes that the patient is experiencing which of the followingsymptoms: o A. Comorbid depression o B. Psychotic hallucinations o C. Negative symptoms of schizophrenia o D. Tardive dyskinesia Correct Answer: D. Tardive dyskinesia Abnormal facial movements and tongue protrusion in a patient taking haloperidol is most likely due to tardive dyskinesia, an adverse reaction to the antipsychotic. Tardive dyskinesia is a syndrome that includes a group of iatrogenic movement disorderscaused by the blockade of dopamine receptors. The movement disorders include akathisia, dystonia, buccolingual stereotypy, myoclonus, chorea, tics and other abnormal involuntary movements which are commonly caused by the long-term use of typical antipsychotics. o Option A: Depression and anxiety is frequently seen in many schizophrenic patients and may be further aggravated or diminished by antipsychotic treatments.Haloperidol is a conventional antipsychotic used in schizophrenia and psychosis. o Option B: Psychotic hallucinations may be visual orauditory but do not include abnormal movements. Hallucinations are most often associated with schizophrenia, a mental illness characterized by disordered thoughts and behaviors. o Option C: Depression may occur along with schizophrenia and would be characterized by such symptoms as loss of affect, appetite and/or sleep changes, and anhedonia. These depressive changes and lack of volition are part of the negative symptomsof schizophrenia. 26 • 20. Question A patient with newly diagnosed diabetes mellitus is learning to recognize the symptoms of hypoglycemia. Which of the following symptoms is indicative of hypoglycemia? o A. Polydipsia o B. Confusion o C. Blurred vision o D. Polyphagia Correct Answer: B. Confusion Hypoglycemia in diabetes mellitus causes confusion, indicating the need for carbohydrates. Neuroglycopenic signs and symptoms are signs and symptoms that result from direct centralnervous system (CNS) deprivation of glucose. These include behavioral changes, confusion, fatigue, seizure, coma, and potential death if not immediately corrected. o Option A: Neurogenic signs and symptoms can eitherbe adrenergic (tremor, palpitations, anxiety) or cholinergic (hunger, diaphoresis, paresthesias). Neurogenic symptoms and signs arise from sympathoadrenal involvement (either norepinephrine or acetylcholine release) in response to perceived hypoglycemia. o Option C: Patients with diabetes mellitus (DM) often experience subjective symptoms of blurred vision associated with hyperglycemia. The nature and origin of this phenomenon are still unclear. Blurred vision during hyperglycemia could be a result of transient refractive alterations due to changes in the lens, but itcould also be caused by changes in the retina. o Option D: Polydipsia, blurred vision, and polyphagia are symptoms of hyperglycemia. Symptoms of severe hyperglycemia include polyuria, polydipsia, and weightloss. As the patient‟s blood glucose increases, neurologic symptoms can develop. The patient may experience lethargy, focal neurologic deficits, or 27 o Option A: This is not included in the staging of Wilms tumor. Imaging is particularly important in surgical planning. Surgical risk factors include larger tumor size, contralateral tumor extension, and displacement of the great vessels which typically result in longer surgical times, increased blood loss, and higher complication rates. o Option B: This described stage I: the tumor is limited to the kidney and completely resected. Stage I indicates the tumor was completely contained within the kidney without any breaks or spillage outside the renal capsule and no vascular invasion. This stage accounts for 40% to 45% of all Wilms tumors. Correct Answer: C. The tumor extended beyond the kidney but was completely resected. Stage II, the tumor extends beyond the kidney but is completely resected. Stage II would be a tumor that has grown outside the kidney to some degree, such as into surrounding fatty tissue. Usually, the tumor would be completely removable by surgery, and regional lymph nodes are negative. About 20% of all Wilms tumors are at this stage. • 21. Question A child is admitted to the hospital with a diagnosis of Wilmstumor, stage II. Which of the following statements most accurately describes this stage? o A. The tumor is less than 3 cm. in size and requires nochemotherapy. o B. The tumor did not extend beyond the kidney and wascompletely resected. o C. The tumor extended beyond the kidney but wascompletely resected. o D. The tumor has spread into the abdominal cavity andcannot be resected. altered mental status. The patient can progress to a comatose state. 30 Acute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group A Streptococcus. PSGN most commonly presents in children 1 to 2 weeks after a streptococcal throat infection, or within 6 weeks following a streptococcal skin infection. Group AStreptococcus (GAS) has been subtyped depending on the surface M protein and opacity factor, which are known to be nephrogenic and can cause PSGN. o Option A: Glomerulonephritis is not a congenital condition. Nephrogenic streptococci infection precedesPSGN, which initially affects skin or oropharynx. More recently, PSGN is associated with skin infections (impetigo) more frequently than throat infections (pharyngitis). o Option C: Glomerular lesions in acute GN are the result of glomerular deposition or in situ formation of immune complexes. Poor hygiene, overcrowding, and low socioeconomic status are important risk factors forstreptococci outbreaks, and this explains the higher incidence of PSGN in impoverished countries. Genetic factors are expected to predispose to the condition since almost 40% of patients with PSGN gave a positive family history. There is no specific gene found to cause PSGN. o Option D: Nephrotic syndrome is the combination of nephrotic-range proteinuria with a low serum albumin level and edema. It is caused by increased permeability through the damaged basement membrane in the renal glomerulus, especially infectious or thrombo-embolic. It is the result of an abnormality of glomerular permeability that may be primary with a disease-specific to the kidneys or secondary to congenital infections, diabetes, systemiclupus erythematosus, neoplasia, or certain drug use. • 24. Question An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of age. The scrotum is smaller than it was at birth, butfluid is still visible on illumination. Which of the following actions is the physician likely to recommend? 31 o A. Massaging the groin area twice a day until the fluid isgone. o B. Referral to a surgeon for repair. o C. No treatment is necessary; the fluid isreabsorbing normally. o D. Keeping the infant in a flat, supine position until thefluid is gone. Correct Answer: C. No treatment is necessary; the fluid isreabsorbing normally. A hydrocele is a collection of fluid in the scrotum that results froma patent tunica vaginalis. Illumination of the scrotum with a pocket light demonstrates the clear fluid. In most cases the fluid reabsorbed within the first few months of life and no treatment is necessary. o Option A: Congenital hydrocele tends to be intermittent as it usually reduces when lying flat due to drainage of hydrocele fluid into the peritoneum. However, applying pressure on the congenital hydrocele does not reduce it. At birth, around 80-90%of term male infants possess a patent processus vaginalis. This figure declines steadily to settle at approximately 25-40% at two years of age. o Option B: Surgery is the treatment of choice for hydrocele, and it is warranted when hydrocele becomes complicated or symptomatic. For congenital hydroceles, herniotomy is performed, provided they donot resolve spontaneously. On the other hand, acquired hydroceles subside when the primary underlying condition resolves. o Option D: Placing the infant in a supine position would have no effect. The majority of patients with hydrocele present with the complaint of painless scrotal swelling rendering the testes impalpable withpositive transillumination and fluctuation. The examiner should look at this swelling in both the supine and upright positions. 32 • 25. Question A nurse is caring for a patient with peripheral vascular disease (PVD). The patient complains of burning and tingling of the handsand feet and cannot tolerate touch of any kind. Which of the following is the most likely explanation for these symptoms? o A. Inadequate tissue perfusion leading to nervedamage. o B. Fluid overload leading to compression of nerve tissue. o C. Sensation distortion due to psychiatric disturbance. o D. Inflammation of the skin on the hands and feet. Correct Answer: A. Inadequate tissue perfusion leading tonerve damage. Patients with peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. Intermittent claudication results when blood flow distal to the occlusion is sufficiently compromised, resulting in fixed oxygen delivery that is unable to match oxygen demand. The most severe form of PADis critical limb ischemia, which is defined as limb pain at rest or impending limb loss. o Option B: Fluid overload is not characteristic of PVD. Atherosclerotic plaque builds up slowly over decades within the wall of the vessel. Plaque accumulation results in vascular stenosis and frequent vascular dilation to maximize end-organ perfusion. Once the vessel dilation capacity is maximized, the plaque continues to accumulate, which further compromises the lumen occasionally, leading to critical narrowing ofthe artery. o Option C: There is nothing to indicate psychiatric disturbance in the patient. The overall prognosis of patients with peripheral vascular disease must take into account patient risk factors, cardiovascular health, and disease severity. In terms of limb health at5 years, nearly 80% of patients will have stable claudication symptoms. Only 1% to 2% of patients will 35 other high-risk groups include people who require frequent bloodtransfusions and organ transplantation of organs from infected donors. o Option B: Cholecystitis is inflammation of the gallbladder that occurs most commonly because of an obstruction of the cystic duct by gallstones arising from the gallbladder (cholelithiasis). Ninety percent ofcases of cholecystitis involve stones in the gallbladder(ie, calculous cholecystitis), with the other 10% of cases representing acalculous cholecystitis. o Option C: Diverticular disease (diverticulosis, diverticulitis) is a general term that refers to the presence of diverticula, small pouches in the large intestinal (colonic) wall. The cause of diverticulosis isunclear, but it has been associated with increased pressure from constipation or increasing abdominal girth in obesity. The classic high-fat and low-fiber dietof the Western culture may be a major contributor tothe development of diverticulosis. o Option D: Crohn‟s disease is an idiopathic, chronic inflammatory process that can affect any part of the gastrointestinal tract from the mouth to the anus. Crohn‟s disease is believed to be the result of an imbalance between proinflammatory and anti- inflammatory mediators. Although genetic susceptibility, luminal antigenic drive, and environmental triggers are also important factors, animal models demonstrate that no single factor is sufficient to induce intestinal inflammation. • 28. Question A physician has diagnosed acute gastritis in a clinic patient. Which of the following medications would be contraindicated forthis patient? o A. naproxen sodium (Naprosyn) o B. calcium carbonate (Tums) o C. clarithromycin (Biaxin) 36 o D. furosemide (Lasix) Correct Answer: A. naproxen sodium (Naprosyn) Naproxen sodium is a nonsteroidal anti-inflammatory drug that can cause inflammation of the upper GI tract. For this reason, it is contraindicated in a patient with gastritis. COX-1 and COX-2 inhibition lead to decreased prostaglandin synthesis in the gastricmucosa. The prostaglandins maintain mucosal integrity, thereforedecreased synthesis causes reduced protection to the tissue. However, studies indicate COX-1 has a more significant effect onthe integrity of the mucosa; consequently, selective COX-2 inhibitors such as Celecoxib do not have as much of an effect ongastric tissue. o Option B: Calcium carbonate is used as an antacid forthe relief of indigestion and is not contraindicated. Calcium carbonate is an inorganic salt primarily used in the management and treatment of low calcium conditions, GERD, CKD, and a variety of other indicated conditions. It is classified as a calcium supplement, antacid, and as a phosphate binder. o Option C: Clarithromycin is an antibacterial often used for the treatment of Helicobacter pylori in gastritis. Clarithromycin is in a class of medications called macrolide antibiotics. It works by stopping the growth of bacteria. Clarithromycin is used to treat certain bacterial infections, such as pneumonia (a lunginfection), bronchitis (infection of the tubes leading to the lungs), and infections of the ears, sinuses, skin, and throat. o Option D: Furosemide is a loop diuretic and is contraindicated in a patient with gastritis. The Food and Drug Administration (FDA) has approved the use of furosemide in the treatment of conditions with volume overload and edema secondary to congestive heart failure exacerbation, liver failure, or renal failureincluding nephrotic syndrome. • 29. Question The nurse is conducting nutrition counseling for a patient with cholecystitis. Which of the following information is important to communicate? 37 o A. The patient must maintain a low calorie diet. o B. The patient must maintain a high protein/lowcarbohydrate diet. o C. The patient should limit sweets and sugary drinks. o D. The patient should limit fatty foods. Correct Answer: D. The patient should limit fatty foods. Cholecystitis, inflammation of the gallbladder, is most commonlycaused by the presence of gallstones, which may block bile (necessary for fat absorption) from entering the intestines. Patients should decrease dietary fat by limiting foods like fatty meats, fried foods, and creamy desserts to avoid irritation of thegallbladder. o Option A: People who go on an extremely low-caloriediet are more likely to develop gallstones than peopleon a moderately low-calorie diet. Eating a healthy, well-balanced diet full of fruits and vegetables is the best way to improve and protect the gallbladder‟s health. Fruits and vegetables are full of nutrients and fiber, the latter of which is essential to a healthy gallbladder. o Option B: A low-fat diet with lean proteins is recommended for patients with cholecystitis. Foods with trans fats, like those in processed or commerciallybaked products, can also be harmful to gallbladder health. o Option C: Moderate consumption of sweet drinks canbe allowed. Avoiding refined white foods, like white pasta, bread, and sugar, can protect the gallbladder. Eat whole-grain cereals, whole-grain bread, whole- grain crackers, brown rice, or whole-grain pasta. Avoidhigh-fat foods such as croissants, scones, biscuits, waffles, doughnuts, muffins, granola, and high-fat bread. • 30. Question 40 • 32. Question A patient returns to the emergency department less than 24 hours after having a fiberglass cast applied for a fractured right radius. Which of the following patient complaints would cause thenurse to be concerned about impaired perfusion to the limb? o A. Severe itching under the cast. o B. Severe pain in the right shoulder. o C. Severe pain in the right lower arm. o D. Increased warmth in the fingers. o Option A: Itching under the cast is common and fairly benign. A cast can cause the client‟ s underlying skin to feel itchy. To relieve itchy skin, turn a hair dryer on a cool setting and aim it under the cast. o Option B: Neurovascular compromise in the arm would not cause pain in the shoulder, as perfusion there would not be affected. Pain is typically severe, out of proportion to the injury. Early on, pain may only be present with passive stretching. However, this symptom may be absent in advanced acute Correct Answer: C. Severe pain in the right lower arm. Impaired perfusion to the right lower arm as a result of a closed cast may cause neurovascular compromise and severe pain, requiring immediate cast removal. When there is an increase in compartmental pressure, there is a reduction in the venous outflow. This causes venous pressure and, thus, venous capillary pressure to increase. If the intracompartmental pressure becomes higher than arterial pressure, a decrease in arterial inflow will also occur. The reduction of venous outflow and arterial inflow result in decreased oxygenation of tissues causing ischemia. dressing less allows the wound bed to be left undisturbed, which allows for the migration of new cells. When wound beds are left undisturbed in an optimal moist environment, they are able to heal at a faster rate. 1 Correct Answer: A. Elevated serum calcium The parathyroid glands regulate the calcium level in the blood. In hyperparathyroidism, the serum calcium level will be elevated. A normal PTH in the presence of hypercalcemia is considered inappropriate and still consistent with PTH-dependent hypercalcemia. PTH levels should be very low in those patients with PTH-independent hypercalcemia. A comprehensive clinical evaluation complemented by routine laboratory and radiologic studies should be sufficient to establish a diagnosis of primary hyperparathyroidism in a patient with persistent hypercalcemia and an elevated serum level of parathyroid hormone. o Option B: Parathyroid hormone levels may be high or normal but not low. Patients with primary hyperparathyroidism and other causes of PTH- dependent hypercalcemia often have frankly elevated levels of PTH, while some will have values that fall within the reference range for the general population. It is uncommon for clinically occult malignancies to cause hypercalcemia. Most patients with malignancy- 1. 1. Question A patient is admitted to the hospital with a diagnosis of primaryhyperparathyroidism. A nurse checking the patient‟s lab resultswould expect which of the following changes in laboratory findings? o A. Elevated serum calcium o B. Low serum parathyroid hormone (PTH) o C. Elevated serum vitamin D o D. Low urine calcium 2 • 2. Question A patient with Addison‟s disease asks a nurse for nutrition anddiet advice. Which of the following diet modifications is not recommended? o A. A diet high in grains. o B. A diet with adequate caloric intake. o C. A high protein diet. o D. A restricted sodium diet. o Option A: Addison‟s disease is a rare condition. It develops when the adrenal glands, which are located above the kidneys, do not make enough of certain hormones. These hormones are important for normal body function. They help the body cope with stress, hold salt and water, and maintain blood pressure. The Correct Answer: D. A restricted sodium diet. A patient with Addison‟s disease requires normal dietary sodium to prevent excess fluid loss. Do not reduce salt in the diet. The client may need to add extra salt to his food during hot and humid weather or after exercise to replace salt lost through sweating. Do not use salt substitutes. associated hypercalcemia are known to have cancer, or cancer is readily detectable on initial evaluation, and PTH levels will be suppressed. o Option C: Parathyroid hormone levels may be high or normal but not low. The body will lower the level of vitamin D in an attempt to lower calcium. o Option D: Urine calcium may be elevated, with calcium spilling over from elevated serum levels. This may cause renal stones. A review of previous medical records can often be of significant value in establishing the cause of hypercalcemia. Most patients with hyperparathyroidism have persistent or intermittent hypercalcemia for many years before a definitive diagnosis is established. 5 o A. Bowel perforation o B. Viral gastroenteritis o C. Colon cancer o D. Diverticulitis Correct Answer: A. Bowel perforation Bowel perforation is the most serious complication of fiberoptic colonoscopy. Important signs include progressive abdominal pain,fever, chills, and tachycardia, which indicate advancing peritonitis. Bowel perforation results from insult or injury to the mucosa of the bowel wall resulting from a violation of the closed system. This exposes the structures within the peritoneal cavity to gastrointestinal contents. Patients presenting with abdominal pain and distension, especially in the appropriate historical setting, must be evaluated for this entity as delayed diagnosis can be life-threatening due to the risk of developing infections such as peritonitis. o Option B: Several different viruses including rotavirus, norovirus, adenovirus, and astroviruses account for most cases of acute viral gastroenteritis. Most are transmitted via the fecal-oral route, includingcontaminated food and water. Transmission has also been shown to occur via fomites, vomitus, and possibly airborne methods. Norovirus is more resistant to chlorine and ethanol inactivation than other viruses.Acute gastroenteritis is defined by loose or watery diarrhea that consists of 3 or more bowel movements in a day. Other symptoms may include nausea, vomiting, fever, or abdominal pain o Option C: Colon cancer does not cause these symptoms. Tumor location on clinical presentation canbe separated on left-sided with more changes in bowelhabits and hematochezia, and right-sided with obscured anemia impacting on late stage at diagnosis.The provider should perform a thorough physical examination for signs of ascites, hepatomegaly, and lymphadenopathy. 6 o Option A: PTT tests the function of all clotting factors except factor VII (tissue factor) and factor XIII (fibrin stabilizing factor). PTT is commonly used in clinical practice to monitor patient response to unfractionated heparin infusion, to target therapeutic anticoagulation, and as part of a “coagulation panel” to help elucidate causes of bleeding or clotting disorders. Correct Answer: A, B, & C Prothrombin time, partial thromboplastin time, and platelet count are all included in coagulation studies. • 5. Question A patient is admitted to the same day surgery unit for liverbiopsy. Which of the following laboratory tests assesses coagulation? Select all that apply. o A. Partial thromboplastin time o B. Prothrombin time o C. Platelet count o D. Hemoglobin o E. Complete Blood Count o F. White Blood Cell Count o Option D: Diverticulitis may cause pain, fever, and chills, but is far less serious than perforation and peritonitis. Acute diverticulitis is inflammation due to micro-perforation of a diverticulum. The diverticulum is a sac-like protrusion of the colon wall. Diverticulitis can present in about 10% to 25% of patients with diverticulosis. Diet appears to play a significant role. Low fiber, high fat, and red meat diets may increase the risk for development of diverticulosis and possible diverticulitis. Obesity and smoking are known to increase the potential for both diverticulitis and diverticular bleeding. 7 o Option B: Prothrombin time (PT) is one of several blood tests routinely used in clinical practice to evaluate the coagulation status of patients. More specifically, PT is used to evaluate the extrinsic and common pathways of coagulation, which would detectdeficiencies of factors II, V, VII, and X, and low fibrinogen concentrations. o Option C: Clinicians can monitor the function of platelets by evaluating the bleeding time, which evaluates the time between breaking the vasculatureand formation of an effective platelet plug. This timemay be elevated in conditions like uremia, in which platelet count is normal but demonstrates impaired function. o Option D: A hemoglobin test measures the levels of hemoglobin in the blood. Hemoglobin is a protein in the red blood cells that carries oxygen from the lungsto the rest of the body. Hemoglobin variant testing measures by percentage, the relative hemoglobin types present in erythrocytes. This testing allows for the detection of hemoglobin variants and thalassemicdisorders. o Option E: A complete blood count (CBC) is a blood test used to evaluate the overall health and detect a wide range of disorders, including anemia, infection and leukemia. A complete blood count test measuresseveral components and features of the blood, including red blood cells, white blood cells, hemoglobin, hematocrit, and platelets. o Option F: A white blood cell (WBC) count is a test thatmeasures the number of white blood cells in the body. Of note, if a subtype of white blood cells seems to be elevated based on the differential, the actual value of the type of white blood cells should be calculated by multiplying the percentage listed on the differential bythe total number of white blood cells. Question • 6. A patient on the cardiac telemetry unit unexpectedly goes into ventricular fibrillation. The advanced cardiac life support team prepares to defibrillate. Which of the following choices indicatesthe correct placement of the conductive gel pads? 10 Correct Answer: A. Irrigate the eye repeatedly with normal saline solution. Emergency treatment following a chemical splash to the eye includes immediate irrigation with normal saline. The irrigation should be continued for at least 10 minutes. Immediate irrigation with copious amounts of an isotonic solution is the mainstay of treatment for chemical burns. Never use any substance to • 8. Question A patient arrives in the emergency department and reports splashing concentrated household cleaner in his eye. Which ofthe following nursing actions is a priority? o A. Irrigate the eye repeatedly with normal salinesolution. o B. Place fluorescein drops in the eye. o C. Patch the eye. o D. Test visual acuity. should be calculated after listening for at least two minutes. Normal bowel sounds are low-pitched and gurgling, and the rate is normally 2-5/min. o Option B: Intestinal obstruction causes the sounds to intensify as the normal flow is blocked by the obstruction. Absent bowel sounds may indicate paralytic ileus and hyperactive rushes (borborygmi) are usually present in small bowel obstruction and sometimes may be auscultated in lactose intolerance o Option C: The swishing and buzzing sound of turbulent blood flow may be heard in the abdomen in the presence of abdominal aortic aneurysm, for example, and should always be considered abnormal. The diaphragm should be placed above the umbilicus to listen for an aortic bruit and then moved 2 cm above and lateral to the umbilicus to listen for a renal bruit. The presence of the former indicates an abdominal aortic aneurysm and the latter indicates renal artery atherosclerosis. 11 Correct Answer: D. Temperature of 101.8 F (38.7 C). neutralize chemical exposure as the exothermic reaction can leadto secondary thermal injuries. Irrigation should continue until the pH of the eye is between 7.0 to 7.4 and remains within this rangefor at least 30 minutes after the irrigation has been discontinued. o Option B: Fluorescein drops are used to check for scratches on the cornea due to their fluorescent properties and are not part of the initial care of a chemical splash. A topical anesthetic such as tetracaine can be applied directly to the eye, or 10 mL of 1% lidocaine can be added to a liter of irrigating fluid, taking care not to reach a toxic dose if copious irrigation is required. o Option C: Patching the eye would not remove the chemical. Severe burns may require upwards of ten liters of irrigation. Irrigation should be gentle, and care should be taken to avoid direct irrigation to the cornea to prevent further injury. Use of a commercial irrigation lens such as a Morgan lens may be helpful. o Option D: Following irrigation, visual acuity will be assessed. Ocular burns, particularly any chemical burns with corneal clouding or abrasions, should have prompt ophthalmology evaluation. Topical antibiotic ointment and possibly topical steroids may be prescribed for both chemical and thermal burns, but topical steroids should only be prescribed in consultation with an ophthalmologist. • 9. Question A nurse is caring for a patient who has had hip replacement. Thenurse should be most concerned about which of the following findings? o A. Complaints of pain during repositioning. o B. Scant bloody discharge on the surgical dressing. o C. Complaints of pain following physical therapy. o D. Temperature of 101.8 F (38.7 C). 12 Post-surgical nursing assessment after hip replacement should beprincipally concerned with the risk of neurovascular complicationsand the development of infection. A temperature of 101.8 F (38.7 C) postoperatively is higher than the low grade that is to be expected and should raise concern. The THA postoperative wound complication spectrum ranges from superficial surgical infections (SSIs) such as cellulitis, superficial dehiscence, and/or delayed wound healing, to deep infections resulting in full- thickness necrosis. Deep infections result in returns to the operating room for irrigation, debridement (incision and drainage)and depending on the timing of the infection, may require explanation of THA components. o Option A: Joint replacement surgery relieves the painand stiffness of arthritis for most people. Some people may still have some symptoms of arthritis. For most people, surgery usually provides enough relief of symptoms for most people. Loosening of the new jointover time can cause pain, and sometimes another surgery is needed to fix the problem. o Option B: A small amount of bloody drainage on the surgical dressing is a result of normal healing. normal to lose blood during and after hip or knee replacementsurgery. Some people need a blood transfusion during surgery or during their recovery period in the hospital.Some surgeries require you to donate blood before surgery. Much of the bleeding during surgery comes from the bone that has been cut. A bruise may occur ifblood collects around the new joint or under the skin after surgery. o Option C: Some pain following physical therapy is to be expected and can be managed with analgesics. As in its counterpart TKA procedure, aseptic loosening is the result of a confluence of steps involving particulatedebris formation, prosthesis micromotion, and macrophage-activated osteolysis. Treatment requires serial imaging and radiographs and/or CT imaging for preoperative planning. Persistent pain requires revision THA surgery. • 10. Question A child is admitted to the hospital with an uncontrolled seizure disorder. The admitting physician writes orders for actions to be 15 Correct Answer: B, C, D & E Polycythemia vera is a condition in which the bone marrow produces too many red blood cells. This causes an increase in hematocrit and viscosity of the blood. Patients can experience headaches, dizziness, tinnitus, and visual disturbances. Cardiovascular effects include increased blood pressure and delayed clotting time. o Option A: Weight loss is not a manifestation of polycythemia vera. Weight loss adversely impacts • 12. Question A patient is admitted to the hospital with suspected polycythemiavera. Which of the following symptoms is consistent with the diagnosis? Select all that apply. o A. Weight loss o B. Increased clotting time o C. Hypertension o D. Headaches o E. Tinnitus o Option C: First-line treatment includes glucocorticoids and intravenous immune globulins; these agents inhibit autoantibody production and platelet degradation. Second-line treatment includes rituximab, immunosuppressive drugs, and splenectomy. Third-line agents are thrombopoietin receptor agonists, which stimulate platelet production. o Option D: Iron supplementation should be taken without food to increase absorption. Low gastric pH facilitates iron absorption. Rapid response to treatment is often seen in 14 days. It is manifested by the rise in hemoglobin levels. Iron supplementation is needed for at least three months to replenish tissue iron stores and should proceed for at least a month even after hemoglobin has returned to normal levels. 16 survival in cancer patients. JAK2 myeloproliferative neoplasms (MPN) upregulate tumor necrosis factor alpha (TNF-?), interleukin-6 (IL-6), and IL-8 and inducedecreased leptin levels leading to weight loss. The impact of weight loss in PV patients receiving best supportive care (i.e. frontline hydroxyurea [HU] therapy, phlebotomy) on overall survival (OS) is largely unknown. o Option B: Bleeding and thrombotic complications areeach observed in 1% of patients. Bleeding events can include epistaxis, gum bleeding, and gastrointestinal (GI) bleeding. Thrombotic events can include deep venous thrombosis (DVT), pulmonary embolism (PE), Budd-Chiari syndrome, splanchnic vein thrombosis, stroke, and arterial thrombosis. o Option C: The overproduction of red blood cells and high hematocrit levels associated with polycythemia vera can contribute to systemic hypertension; high hematocrit levels have been found to interfere with the vasodilatory effects of nitric oxide. The treatment of polycythemia, which can involve phlebotomy, can alleviate the systemic hypertension, as well as the physiological consequences of having a high red bloodcell count. o Option D: As polycythemia vera is a myeloproliferative syndrome, it is based on an autonomic increase in the proliferation of all hematopoietic cells–mostly of erythropoiesis. An increase in blood viscosity induces disturbed microcirculation, resulting in headaches with clinicalsymptoms. o Option E: Symptoms are related to hyperviscosity and thrombosis, impairing oxygen delivery. Physical complaints can include fatigue, headache, dizziness,tinnitus, vision changes, insomnia, claudication, pruritus, gastritis, and early satiety. • 13. Question A nurse is caring for a patient with a platelet count of 20,000/microliter. Which of the following is an importantintervention? 17 o A. Observe for evidence of spontaneous bleeding. o B. Limit visitors to family only. o C. Give aspirin in case of headaches. o D. Impose immune precautions. Correct Answer: A. Observe for evidence of spontaneousbleeding. Platelet counts under 30,000/microliter may cause spontaneous petechiae and bruising, particularly in the extremities. When thecount falls below 15,000, spontaneous bleeding into the brain and internal organs may occur. The blood clotting cascade is an integral system requiring intrinsic and extrinsic factors. Derangements in any factors can affect clotting ability. These laboratory tests provide important information about the patient‟scoagulation status and bleeding potential. The specific laboratory values to be monitored will depend on the patient‟s specific clinical condition. o Option B: There is no reason to limit visitors as long as any physical trauma is prevented. Educate the patient and family members about signs of bleeding that need to be reported to a health care provider. Early evaluation and treatment of bleeding by a healthcare provider reduce the risk for complications from blood loss. o Option C: Headaches may be a sign and should be watched for. Aspirin disables platelets and should never be used in the presence of thrombocytopenia. Educate the patient about over-the-counter drugs andavoid products that contain aspirin or NSAIDs such as ibuprofen and naproxen. These drugs not only decrease normal platelet aggregation but also decrease the integrity of gastric mucosa through inhibition of cyclooxygenase (COX)-1 inhibitor and therefore increase the risk for gastrointestinal bleeding. o Option D: Thrombocytopenia does not compromiseimmunity. Educate the at-risk patient about precautionary measures to prevent tissue trauma or 20 o D. Minimize conversation with the patient. Correct Answer: B. Change gloves immediately after use. The neutropenic patient is at risk of infection. Changing gloves immediately after use protects patients from contamination with organisms picked up onhospital surfaces. This contamination canhave serious consequences for an immunocompromised patient.Wear gloves when providing direct care; perform hand hygiene after properly disposing gloves. o Option A: Changing the respiratory mask is desirable,but not nearly as urgent as changing gloves. Wear personal protective equipment (PPE) properly. Use masks, goggles, face shields to protect the mucous membranes of your eyes, mouth, and nose during procedures and in direct-care activities (e.g., suctioning secretions) that may generate splashes or sprays of blood, body fluids, secretions, and excretions. o Option C: Place the patient in protective isolation if the patient is at high risk of infection. Protective isolation is set when the WBC indicates neutropenia. Provide surgical masks to visitors who are coughing and provide rationale to enforce usage. Instruct visitors to cover mouth and nose (by using the elbowsto cover) during coughing or sneezing; use of tissues to contain respiratory secretions with immediate disposal to a no-touch receptacle; perform hand hygiene afterward. o Option D: Minimizing conversations are not necessaryand may cause nursing staff to miss changes in the patient‟s symptoms or condition. Educating visitors on the importance of preventing droplet transmission from themselves to others reduces the risk of infection. • 16. Question A nurse is counseling patients at a health clinic on the importanceof immunizations. Which of the following information is the most accurate regarding immunizations? 21 o A. All infectious diseases can be prevented with properimmunization. o B. Immunizations provide natural immunity fromdisease. o C. Immunizations are risk-free and should be universallyadministered. o D. Immunization provides acquired immunity fromsome specific diseases. Correct Answer: D. Immunization provides acquiredimmunity from some specific diseases. Immunization is available for the prevention of some, but not all, specific diseases. This type of immunity is “acquired” by causing antibodies to form in response to a specific pathogen. Live vaccines are more effective than killed vaccines because they retain more antigens of the microbes. However, toxoids, includingthose that cause tetanus and diphtheria, are the most effective bacterial vaccines of all because they are based on inactivated exotoxins that stimulate strong antibody production. Subunit vaccines, including hepatitis B, meningococcal, and Haemophilus influenzae B vaccines are effective when conjugated to carrier proteins such as tetanus toxoid. o Option A: Immunizations can prevent some, but not all, infectious diseases. The current immunizations protect against diphtheria, tetanus, pertussis, poliomyelitis, measles, mumps, rubella, pneumococcalpneumonia, smallpox, sepsis, meningitis, hepatitis B, varicella-zoster, tuberculosis, cholera, diarrhea causedby rotavirus, salmonellosis, and dengue. o Option B: Natural immunity is present at birth because the infant acquires maternal antibodies. Innate (natural) immunity is so named because it is present at birth and does not have to be learned through exposure to an invader. It thus provides an immediate response to foreign invaders. However, itscomponents treat all foreign invaders in much the same way. 22 o Option A: The physician will see the patient as soon as possible with the above actions underway. Often when anaphylaxis is diagnosed co-treatment is initiated with steroids, antihistamines, inhaled bronchodilators, and vasopressors. Glucagon can also be used if indicated. These agents can assist in Correct Answer: B. Maintain a patent airway. The patient may be experiencing an anaphylactic reaction. Airway management is paramount. Thoroughly examine the patient for airway patency or any indications of an impending loss of airway. Perioral edema, stridor, and angioedema are very high risk, and obtaining a definitive airway is imperative. Delay may reduce the chances of successful intubation as continued swelling occurs, increasing the risk for a surgical airway. • 17. Question A patient is brought to the emergency department after a bee sting. The family reports a history of severe allergic reaction, andthe patient appears to have some oral swelling. Which of the following is the most urgent nursing action? o A. Consult a physician. o B. Maintain a patent airway. o C. Administer epinephrine subcutaneously. o D. Administer diphenhydramine (Benadryl) orally. o Option C: Immunization, like all medication, cannot be risk-free and should be considered based on the risk of the disease in question. Most vaccines have adverse reactions as any drug or medication. For example, BCG vaccination may provoke fever, vomiting, hematuria, lymphadenitis, and redness at the site of injection. HiB vaccine has few adverse reactions, and none of them are dangerous. These reactions include redness, warmth, swelling, and fever over 101 degrees F. A rare and lethal adverse reaction secondary to vaccination is the Guillain-Barre syndrome. 25 A patient at a mental health clinic is taking Haldol (haloperidol) for treatment of schizophrenia. She calls the clinic to report abnormal movements of her face and tongue. The nurse concludes that the patient is experiencing which of the followingsymptoms: o A. Comorbid depression o B. Psychotic hallucinations o C. Negative symptoms of schizophrenia o D. Tardive dyskinesia Correct Answer: D. Tardive dyskinesia Abnormal facial movements and tongue protrusion in a patient taking haloperidol is most likely due to tardive dyskinesia, an adverse reaction to the antipsychotic. Tardive dyskinesia is a syndrome that includes a group of iatrogenic movement disorderscaused by the blockade of dopamine receptors. The movement disorders include akathisia, dystonia, buccolingual stereotypy, myoclonus, chorea, tics and other abnormal involuntary movements which are commonly caused by the long-term use of typical antipsychotics. o Option A: Depression and anxiety is frequently seen in many schizophrenic patients and may be further aggravated or diminished by antipsychotic treatments.Haloperidol is a conventional antipsychotic used in schizophrenia and psychosis. o Option B: Psychotic hallucinations may be visual orauditory but do not include abnormal movements. Hallucinations are most often associated with schizophrenia, a mental illness characterized by disordered thoughts and behaviors. o Option C: Depression may occur along with schizophrenia and would be characterized by such symptoms as loss of affect, appetite and/or sleep changes, and anhedonia. These depressive changes and lack of volition are part of the negative symptomsof schizophrenia. 26 • 20. Question A patient with newly diagnosed diabetes mellitus is learning to recognize the symptoms of hypoglycemia. Which of the following symptoms is indicative of hypoglycemia? o A. Polydipsia o B. Confusion o C. Blurred vision o D. Polyphagia Correct Answer: B. Confusion Hypoglycemia in diabetes mellitus causes confusion, indicating the need for carbohydrates. Neuroglycopenic signs and symptoms are signs and symptoms that result from direct centralnervous system (CNS) deprivation of glucose. These include behavioral changes, confusion, fatigue, seizure, coma, and potential death if not immediately corrected. o Option A: Neurogenic signs and symptoms can eitherbe adrenergic (tremor, palpitations, anxiety) or cholinergic (hunger, diaphoresis, paresthesias). Neurogenic symptoms and signs arise from sympathoadrenal involvement (either norepinephrine or acetylcholine release) in response to perceived hypoglycemia. o Option C: Patients with diabetes mellitus (DM) often experience subjective symptoms of blurred vision associated with hyperglycemia. The nature and origin of this phenomenon are still unclear. Blurred vision during hyperglycemia could be a result of transient refractive alterations due to changes in the lens, but itcould also be caused by changes in the retina. o Option D: Polydipsia, blurred vision, and polyphagia are symptoms of hyperglycemia. Symptoms of severe hyperglycemia include polyuria, polydipsia, and weightloss. As the patient‟s blood glucose increases, neurologic symptoms can develop. The patient may experience lethargy, focal neurologic deficits, or 27 o Option A: This is not included in the staging of Wilms tumor. Imaging is particularly important in surgical planning. Surgical risk factors include larger tumor size, contralateral tumor extension, and displacement of the great vessels which typically result in longer surgical times, increased blood loss, and higher complication rates. o Option B: This described stage I: the tumor is limited to the kidney and completely resected. Stage I indicates the tumor was completely contained within the kidney without any breaks or spillage outside the renal capsule and no vascular invasion. This stage accounts for 40% to 45% of all Wilms tumors. Correct Answer: C. The tumor extended beyond the kidney but was completely resected. Stage II, the tumor extends beyond the kidney but is completely resected. Stage II would be a tumor that has grown outside the kidney to some degree, such as into surrounding fatty tissue. Usually, the tumor would be completely removable by surgery, and regional lymph nodes are negative. About 20% of all Wilms tumors are at this stage. • 21. Question A child is admitted to the hospital with a diagnosis of Wilmstumor, stage II. Which of the following statements most accurately describes this stage? o A. The tumor is less than 3 cm. in size and requires nochemotherapy. o B. The tumor did not extend beyond the kidney and wascompletely resected. o C. The tumor extended beyond the kidney but wascompletely resected. o D. The tumor has spread into the abdominal cavity andcannot be resected. altered mental status. The patient can progress to a comatose state. 30 Acute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group A Streptococcus. PSGN most commonly presents in children 1 to 2 weeks after a streptococcal throat infection, or within 6 weeks following a streptococcal skin infection. Group AStreptococcus (GAS) has been subtyped depending on the surface M protein and opacity factor, which are known to be nephrogenic and can cause PSGN. o Option A: Glomerulonephritis is not a congenital condition. Nephrogenic streptococci infection precedesPSGN, which initially affects skin or oropharynx. More recently, PSGN is associated with skin infections (impetigo) more frequently than throat infections (pharyngitis). o Option C: Glomerular lesions in acute GN are the result of glomerular deposition or in situ formation of immune complexes. Poor hygiene, overcrowding, and low socioeconomic status are important risk factors forstreptococci outbreaks, and this explains the higher incidence of PSGN in impoverished countries. Genetic factors are expected to predispose to the condition since almost 40% of patients with PSGN gave a positive family history. There is no specific gene found to cause PSGN. o Option D: Nephrotic syndrome is the combination of nephrotic-range proteinuria with a low serum albumin level and edema. It is caused by increased permeability through the damaged basement membrane in the renal glomerulus, especially infectious or thrombo-embolic. It is the result of an abnormality of glomerular permeability that may be primary with a disease-specific to the kidneys or secondary to congenital infections, diabetes, systemiclupus erythematosus, neoplasia, or certain drug use. • 24. Question An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of age. The scrotum is smaller than it was at birth, butfluid is still visible on illumination. Which of the following actions is the physician likely to recommend? 31 o A. Massaging the groin area twice a day until the fluid isgone. o B. Referral to a surgeon for repair. o C. No treatment is necessary; the fluid isreabsorbing normally. o D. Keeping the infant in a flat, supine position until thefluid is gone. Correct Answer: C. No treatment is necessary; the fluid isreabsorbing normally. A hydrocele is a collection of fluid in the scrotum that results froma patent tunica vaginalis. Illumination of the scrotum with a pocket light demonstrates the clear fluid. In most cases the fluid reabsorbed within the first few months of life and no treatment is necessary. o Option A: Congenital hydrocele tends to be intermittent as it usually reduces when lying flat due to drainage of hydrocele fluid into the peritoneum. However, applying pressure on the congenital hydrocele does not reduce it. At birth, around 80-90%of term male infants possess a patent processus vaginalis. This figure declines steadily to settle at approximately 25-40% at two years of age. o Option B: Surgery is the treatment of choice for hydrocele, and it is warranted when hydrocele becomes complicated or symptomatic. For congenital hydroceles, herniotomy is performed, provided they donot resolve spontaneously. On the other hand, acquired hydroceles subside when the primary underlying condition resolves. o Option D: Placing the infant in a supine position would have no effect. The majority of patients with hydrocele present with the complaint of painless scrotal swelling rendering the testes impalpable withpositive transillumination and fluctuation. The examiner should look at this swelling in both the supine and upright positions. 32 • 25. Question A nurse is caring for a patient with peripheral vascular disease (PVD). The patient complains of burning and tingling of the handsand feet and cannot tolerate touch of any kind. Which of the following is the most likely explanation for these symptoms? o A. Inadequate tissue perfusion leading to nervedamage. o B. Fluid overload leading to compression of nerve tissue. o C. Sensation distortion due to psychiatric disturbance. o D. Inflammation of the skin on the hands and feet. Correct Answer: A. Inadequate tissue perfusion leading tonerve damage. Patients with peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. Intermittent claudication results when blood flow distal to the occlusion is sufficiently compromised, resulting in fixed oxygen delivery that is unable to match oxygen demand. The most severe form of PADis critical limb ischemia, which is defined as limb pain at rest or impending limb loss. o Option B: Fluid overload is not characteristic of PVD. Atherosclerotic plaque builds up slowly over decades within the wall of the vessel. Plaque accumulation results in vascular stenosis and frequent vascular dilation to maximize end-organ perfusion. Once the vessel dilation capacity is maximized, the plaque continues to accumulate, which further compromises the lumen occasionally, leading to critical narrowing ofthe artery. o Option C: There is nothing to indicate psychiatric disturbance in the patient. The overall prognosis of patients with peripheral vascular disease must take into account patient risk factors, cardiovascular health, and disease severity. In terms of limb health at5 years, nearly 80% of patients will have stable claudication symptoms. Only 1% to 2% of patients will 35 other high-risk groups include people who require frequent bloodtransfusions and organ transplantation of organs from infected donors. o Option B: Cholecystitis is inflammation of the gallbladder that occurs most commonly because of an obstruction of the cystic duct by gallstones arising from the gallbladder (cholelithiasis). Ninety percent ofcases of cholecystitis involve stones in the gallbladder(ie, calculous cholecystitis), with the other 10% of cases representing acalculous cholecystitis. o Option C: Diverticular disease (diverticulosis, diverticulitis) is a general term that refers to the presence of diverticula, small pouches in the large intestinal (colonic) wall. The cause of diverticulosis isunclear, but it has been associated with increased pressure from constipation or increasing abdominal girth in obesity. The classic high-fat and low-fiber dietof the Western culture may be a major contributor tothe development of diverticulosis. o Option D: Crohn‟s disease is an idiopathic, chronic inflammatory process that can affect any part of the gastrointestinal tract from the mouth to the anus. Crohn‟s disease is believed to be the result of an imbalance between proinflammatory and anti- inflammatory mediators. Although genetic susceptibility, luminal antigenic drive, and environmental triggers are also important factors, animal models demonstrate that no single factor is sufficient to induce intestinal inflammation. • 28. Question A physician has diagnosed acute gastritis in a clinic patient. Which of the following medications would be contraindicated forthis patient? o A. naproxen sodium (Naprosyn) o B. calcium carbonate (Tums) o C. clarithromycin (Biaxin) 36 o D. furosemide (Lasix) Correct Answer: A. naproxen sodium (Naprosyn) Naproxen sodium is a nonsteroidal anti-inflammatory drug that can cause inflammation of the upper GI tract. For this reason, it is contraindicated in a patient with gastritis. COX-1 and COX-2 inhibition lead to decreased prostaglandin synthesis in the gastricmucosa. The prostaglandins maintain mucosal integrity, thereforedecreased synthesis causes reduced protection to the tissue. However, studies indicate COX-1 has a more significant effect onthe integrity of the mucosa; consequently, selective COX-2 inhibitors such as Celecoxib do not have as much of an effect ongastric tissue. o Option B: Calcium carbonate is used as an antacid forthe relief of indigestion and is not contraindicated. Calcium carbonate is an inorganic salt primarily used in the management and treatment of low calcium conditions, GERD, CKD, and a variety of other indicated conditions. It is classified as a calcium supplement, antacid, and as a phosphate binder. o Option C: Clarithromycin is an antibacterial often used for the treatment of Helicobacter pylori in gastritis. Clarithromycin is in a class of medications called macrolide antibiotics. It works by stopping the growth of bacteria. Clarithromycin is used to treat certain bacterial infections, such as pneumonia (a lunginfection), bronchitis (infection of the tubes leading to the lungs), and infections of the ears, sinuses, skin, and throat. o Option D: Furosemide is a loop diuretic and is contraindicated in a patient with gastritis. The Food and Drug Administration (FDA) has approved the use of furosemide in the treatment of conditions with volume overload and edema secondary to congestive heart failure exacerbation, liver failure, or renal failureincluding nephrotic syndrome. • 29. Question The nurse is conducting nutrition counseling for a patient with cholecystitis. Which of the following information is important to communicate? 37 o A. The patient must maintain a low calorie diet. o B. The patient must maintain a high protein/lowcarbohydrate diet. o C. The patient should limit sweets and sugary drinks. o D. The patient should limit fatty foods. Correct Answer: D. The patient should limit fatty foods. Cholecystitis, inflammation of the gallbladder, is most commonlycaused by the presence of gallstones, which may block bile (necessary for fat absorption) from entering the intestines. Patients should decrease dietary fat by limiting foods like fatty meats, fried foods, and creamy desserts to avoid irritation of thegallbladder. o Option A: People who go on an extremely low-caloriediet are more likely to develop gallstones than peopleon a moderately low-calorie diet. Eating a healthy, well-balanced diet full of fruits and vegetables is the best way to improve and protect the gallbladder‟s health. Fruits and vegetables are full of nutrients and fiber, the latter of which is essential to a healthy gallbladder. o Option B: A low-fat diet with lean proteins is recommended for patients with cholecystitis. Foods with trans fats, like those in processed or commerciallybaked products, can also be harmful to gallbladder health. o Option C: Moderate consumption of sweet drinks canbe allowed. Avoiding refined white foods, like white pasta, bread, and sugar, can protect the gallbladder. Eat whole-grain cereals, whole-grain bread, whole- grain crackers, brown rice, or whole-grain pasta. Avoidhigh-fat foods such as croissants, scones, biscuits, waffles, doughnuts, muffins, granola, and high-fat bread. • 30. Question 40 • 32. Question A patient returns to the emergency department less than 24 hours after having a fiberglass cast applied for a fractured right radius. Which of the following patient complaints would cause thenurse to be concerned about impaired perfusion to the limb? o A. Severe itching under the cast. o B. Severe pain in the right shoulder. o C. Severe pain in the right lower arm. o D. Increased warmth in the fingers. o Option A: Itching under the cast is common and fairly benign. A cast can cause the client‟ s underlying skin to feel itchy. To relieve itchy skin, turn a hair dryer on a cool setting and aim it under the cast. o Option B: Neurovascular compromise in the arm would not cause pain in the shoulder, as perfusion there would not be affected. Pain is typically severe, out of proportion to the injury. Early on, pain may only be present with passive stretching. However, this symptom may be absent in advanced acute Correct Answer: C. Severe pain in the right lower arm. Impaired perfusion to the right lower arm as a result of a closed cast may cause neurovascular compromise and severe pain, requiring immediate cast removal. When there is an increase in compartmental pressure, there is a reduction in the venous outflow. This causes venous pressure and, thus, venous capillary pressure to increase. If the intracompartmental pressure becomes higher than arterial pressure, a decrease in arterial inflow will also occur. The reduction of venous outflow and arterial inflow result in decreased oxygenation of tissues causing ischemia. dressing less allows the wound bed to be left undisturbed, which allows for the migration of new cells. When wound beds are left undisturbed in an optimal moist environment, they are able to heal at a faster rate. 41 Correct Answer: A. Increased physical activity and daily exercise will help decrease discomfort associated with the condition. Physical activity and daily exercise can help to improve movement and decrease pain in osteoarthritis. Exercise programs that combine both aerobic and resistance training have been shown to decrease pain and improve physical function in multiple trials and should be encouraged by physicians regularly. o Option B: Joint pain and stiffness are often at their worst during the early morning after several hours of decreased movement. Evidence shows that water- based activities can help relieve symptoms and • 33. Question An older patient with osteoarthritis is preparing for discharge.Which of the following information is correct. o A. Increased physical activity and daily exercisewill help decrease discomfort associated with the condition. o B. Joint pain will diminish after a full night of rest. o C. Nonsteroidal anti-inflammatory medications should betaken on an empty stomach. o D. Acetaminophen (Tylenol) is a more effective anti-inflammatory than ibuprofen (Motrin). compartment syndrome. In the initial stages, pain may be characterized as a burning sensation or as a deep ache of the involved compartment. o Option D: Impaired perfusion would cause the fingers to be cool and pale. Increased warmth would indicate increased blood flow or infection. Classically, the presentation of acute compartment syndrome has been remembered by “The Five P‟s”: pain, pulselessness, paresthesia, paralysis, and pallor. However, aside from paresthesia, which may occur earlier in the course of the condition, these are typically late findings. 42 Correct Answer: D. A patient on bed rest who must maintain a supine position. Alendronate can cause significant gastrointestinal side effects, such as esophageal irritation, so it should not be taken if a patient must stay in supine position. It should be taken upon rising in the morning with 8 ounces of water on an empty stomach to increase absorption. The patient should not eat or drink for 30 minutes after administration and should not lie down. • 34. Question Which patient should not be prescribed alendronate (Fosamax)for osteoporosis? o A. A female patient being treated for high blood pressurewith an ACE inhibitor. o B. A patient who is allergic to iodine/shellfish. o C. A patient on a calorie restricted diet. o D. A patient on bed rest who must maintain asupine position. improve joint function, hence consultation with a physical therapist is recommended. Further, many of these patients may benefit from a walking aid. o Option C: Ibuprofen is a strong anti-inflammatory, but should always be taken with food to avoid GI distress. NSAIDs are usually prescribed orally or topically and initially, should be started as needed rather than scheduled. Due to gastrointestinal toxicity, and renal and cardiovascular side effects, oral NSAIDs should be used very cautiously and with close monitoring long term. o Option D: Acetaminophen is a pain reliever, but does not have anti-inflammatory activity. Pharmacotherapy of OA involves oral, topical, and/or intra-articular options. Acetaminophen and oral NSAIDs are the most popular and affordable options for OA and are usually the initial choice of pharmacologic treatment. 45 o C. The IV solution is infusing too slowly, particularlywhen the limb is elevated. o D. A hematoma is visible in the area of the IV insertionsite. Correct Answer: B. The area proximal to the insertion siteis reddened, warm, and painful. An IV site that is red, warm, painful and swollen indicates that phlebitis has developed and the line should be discontinued and restarted at another site. Phlebitis is inflammation of a vein. It is usually associated with acidic or alkaline solutions or solutions that have a high osmolarity. Phlebitis can also occur as a result ofvein trauma during insertion, use of an inappropriate I.V. cathetersize for the vein, or prolonged use of the same I.V. site. o Option A: Pain on movement should be managed by maneuvers such as splinting the limb with an IV boardor gently shifting the position of the catheter before making a decision to remove the line. Apply warm, moist compresses to the area. Document the patient‟scondition and interventions. o Option C: An IV line that is running slowly may simplyneed flushing or repositioning. Monitor administration rates and inspect the I.V. site frequently. Change the infusion site according to the facility‟s policy. o Option D: A hematoma at the site is likely a result of minor bleeding at the time of insertion and does not require discontinuation of the line. Avoid veins that aresmall and/or fragile, veins in areas of flexion, veins in extremities with preexisting edema, or veins in areas with known neurologic impairment. • 37. Question A hospitalized patient has received transfusions of 2 units of blood over the past few hours. A nurse enters the room to find the patient sitting up in bed, dyspneic and uncomfortable. On assessment, crackles are heard in the bases of both lungs, probably indicating that the patient is experiencing a complication of transfusion. Which of the following complicationsis most likely the cause of the patient‟s symptoms? 46 o A. Febrile non-hemolytic reaction o B. Allergic transfusion reaction o C. Acute hemolytic reaction o D. Fluid overload Correct Answer: D. Fluid overload Fluid overload occurs when the fluid volume infused over a short period is too great for the vascular system, causing fluid leak intothe lungs. Symptoms include dyspnea, rapid respirations, and discomfort as in the patient described. Transfusion associated circulatory overload includes any four of the following occurring within 6 h of a BT – acute respiratory distress, tachycardia, increased blood pressure (BP), acute or worsening pulmonary edema and evidence of a positive fluid balance. o Option A: Febrile non-hemolytic reaction results in fever. Febrile non-hemolytic is generally thought to be caused by cytokines released from blood donor leukocytes (white blood cells). Transfusion reactions range in frequency from relatively common (mild allergic and febrile non-hemolytic reactions) to rare (anaphylaxis, acute hemolytic, and sepsis). o Option B: Symptoms of allergic transfusion reaction would include flushing, itching, and a generalized rash. Attributed to hypersensitivity to a foreign protein in the donor product. The severity and incidence vary depending on the type of transfusion reaction, the prevalence of disease in the donor population, and the extent of follow-up care the patient receives. o Option C: Acute hemolytic reaction may occur when apatient receives blood that is incompatible with his blood type. It is the most serious adverse transfusion reaction and can cause shock and death. Can result in intravascular or extravascular hemolysis, depending on the specific etiology (cause). Immune-mediated reactions are often a result of recipient antibodies present to blood donor antigens. • 38. Question 47 A patient in labor and delivery has just received an amniotomy.Which of the following is correct? Select all that apply. o A. Frequent checks for cervical dilation will be neededafter the procedure. o B. Contractions may rapidly become stronger andcloser together after the procedure. o C. The FHR (fetal heart rate) will be followed closely after the procedure due to the possibility ofcord compression. o D. The procedure is usually painless and isfollowed by a gush of amniotic fluid. o E. The procedure is without pain. Correct Answer: B, C, D & E. Uterine contractions typically become stronger and occur more closely together following amniotomy. The FHR is assessed immediately after the procedure and followed closely to detect changes that may indicate cord compression. The procedure itselfis painless and results in the quick expulsion of amniotic fluid. o Option A: Following amniotomy, cervical checks are minimized because of the risk of infection. Amniotomyis easily performed with the use of specially designed hooks intended to grab and tear the amniotic membrane. The two most commonly used devices are (1) an approximately 10-inch rod with a hook on the end of the rod or (2) a finger cot with a hook on the end of the cot. With either device, the practitioner firstassesses cervical dilation through the performance of a sterile digital exam. o Option B: It is commonly felt that relieving the amniotic sac of amniotic fluid induces uterine contraction activity, increases the strength of contractions, and may augment labor by allowingdirect pressure from the fetal scalp on the uterinecervix which may assist in dilating the cervix. 50 Correct Answer: A. The infant should be restrained in an infant car seat, properly secured in the back seat in a rear-facing position. All infants under 1 year of age weighing less than 20 lbs. should be placed in a rear-facing infant car seat secured properly in the back seat. Rear-facing car safety seats for infants are perhaps the least controversial; rear-facing car seats have superior effectiveness in preventing serious injury in infants from car crashes. Children < 24 months riding in rear-facing car seats were 1.76 times less likely be seriously injured from all types of car crashes relative to children riding in forward-facing safety seats o Option B: Infant car seats should never be placed in the front passenger seat. States have implemented their own individual mandates for car safety seats, with stringent recommendations from the AAP incorporated into law in New Jersey and Oklahoma and with states including West Virginia (WV) and North Carolina having the most lenient requirements (Bae, • 40. Question A nurse is giving discharge instructions to the parents of a healthy newborn. Which of the following instructions should thenurse provide regarding car safety and the trip home from the hospital? o A. The infant should be restrained in an infant carseat, properly secured in the back seat in a rear- facing position. o B. The infant should be restrained in an infant car seat,properly secured in the front passenger seat. o C. The infant should be restrained in an infant car seatfacing forward or rearward in the back seat. o D. For the trip home from the hospital, the parent maysit in the back seat and hold the newborn. motility and decreases the elimination of bilirubin in the stool or meconium. 51 Correct Answer: C. Decreased pain Furosemide, a loop diuretic, does not alter pain. The Food and Drug Administration (FDA) has approved the use of furosemide in the treatment of conditions with volume overload and edema • 41. Question A nurse is administering IV furosemide to a patient admitted with congestive heart failure. After the infusion, which of the following symptoms is not expected? o A. Increased urinary output o B. Decreased edema o C. Decreased pain o D. Decreased blood pressure Anderson, Silver, & Macinko, 2014; NCPSC, 2013). WV requires that children under 7 years be restrained in a car safety or booster seat, without specifying the timing of the transition. o Option C: The infant should always face rearward in the back seat while on a car seat. For side crashes, children < 24 months riding in forward-facing car seats were 5.5 times more likely to get injured as compared to those riding in rear-facing car seats. Accident data (such as from Sweden) indicate that increased duration of rear-facing car safety seat usage can decrease injuries and deaths relating to automobile accidents (SafetyBeltSafe USA, 2013). o Option D: Infants should always be placed in an approved car seat during travel, even on that first ride home from the hospital. Consistent with research, the American Academy of Pediatrics (AAP) and National Highway Traffic Safety Administration (NHTSA) have developed evidence-based practice guidelines for car safety seat use, which vary by the size and weight of the child, emphasizing the use of rear seats among infants less than 2 years of age (AAP, 2013; NHTSA, 2014). 52 secondary to congestive heart failure exacerbation, liver failure,or renal failure including the nephrotic syndrome. o Option A: Furosemide acts on the kidneys to increase urinary output. Furosemide inhibits tubular reabsorption of sodium and chloride in the proximal and distal tubules, as well as in the thick ascending loop of Henle by inhibiting sodium-chloride cotransportsystem resulting in excessive excretion of water along with sodium, chloride, magnesium, and calcium. o Option B: Fluid may move from the periphery, decreasing edema. Careful monitoring of the clinical condition of the patient, daily weight, fluids intake, and urine output, electrolytes, i.e., potassium and magnesium, kidney function monitoring with serum creatinine and serum blood urea nitrogen level is vitalto monitor the response to furosemide. Replete electrolytes if indicated as diuresis with furosemide lead to electrolyte depletion, and adjust the dose or even hold off on furosemide if laboratory work shows signs of kidney dysfunction. o Option D: Fluid load is reduced, lowering blood pressure. Furosemide can be a second-line agent in heart failure patients with symptoms, and in patientswith advanced kidney disease with an estimated glomerular filtration rate, less than 30 ml per minutethe loop diuretics (furosemide) are preferred over thiazide diuretics to treat hypertension. • 42. Question There are a number of risk factors associated with coronary artery disease. Which of the following is a modifiable risk factor? o A. Obesity o B. Heredity o C. Gender o D. Age Correct Answer: A. Obesity 55 Following myocardial infarction, a hospitalized patient is encouraged to practice frequent leg exercises and ambulate in the hallway as directed by his physician. Which of the followingchoices reflects the purpose of exercise for this patient? o A. Increases fitness and prevents future heart attacks. o B. Prevents bedsores. o C. Prevents DVT (deep vein thrombosis). o D. Prevent constipations. Correct Answer: C. Prevents DVT (deep vein thrombosis). Exercise is important for all hospitalized patients to prevent deep vein thrombosis. Muscular contraction promotes venous return and prevents hemostasis in the lower extremities. Encourage physical activity consistent with the patient‟s energy levels. Helpspromote a sense of autonomy while being realistic about capabilities. Walking down the hall 20 feet or walking through the house, then slowly progressing walking outside the house, saving energy for the return trip. o Option A: This exercise is not sufficiently vigorous to increase physical fitness. Encourage active ROM exercises. Encourage the patient to participate in planning activities that gradually build endurance. Exercise maintains muscle strength, joint ROM, and exercise tolerance. Physical inactive patients need to improve functional capacity through repetitive exercises over a long period of time. Strength trainingis valuable in enhancing endurance of many ADLs. o Option B: Inspect skin regularly, particularly over bony prominences. Gently massage any reddened areas and provide aids such as sheepskin pads as necessary. Pressure points over bony prominences aremost at risk for decreased perfusion. Circulatory stimulation and padding help prevent skin breakdown and decubitus development. Change positions at leastevery 2 hr (supine, side-lying) and possibly more oftenif placed on the affected side. 56 • 45. Question A patient arrives in the emergency department with symptoms ofmyocardial infarction, progressing to cardiogenic shock. Which of the following symptoms should the nurse expect the patient to exhibit with cardiogenic shock? o A. Hypertension o B. Bradycardia o C. Bounding pulse o D. Confusion o Option A: If a sufficient area of myocardium undergoes ischemic injury, LV pump function becomes depressed and systemic hypotension develops. The pathophysiology of cardiogenic shock is complex and not fully understood. Ischemia to the myocardium causes derangement to both systolic and diastolic left ventricular function, resulting in a profound depression of myocardial contractility. This, in turn, leads to a potentially catastrophic and vicious spiral of reduced cardiac output and low blood pressure, perpetuating further coronary ischemia and impairment of contractility. Correct Answer: D. Confusion Cardiogenic shock severely impairs the pumping function of the heart muscle, causing diminished blood flow to the organs of the body. This results in diminished brain function and confusion. Cardiogenic shock is a primary cardiac disorder characterized by a low cardiac output state of circulatory failure that results in end-organ hypoperfusion and tissue hypoxia. o Option D: It is not intended to prevent bedsores or constipation. Have the patient perform the activity more slowly, in a longer time with more rest or pauses, or with assistance if necessary. Gradually increase activity with active range-of-motion exercises in bed, increasing to sitting and then standing. Gradual progression of the activity prevents overexertion. 57 • 46. Question A patient in the cardiac unit is concerned about the risk factorsassociated with atherosclerosis. Which of the following are hereditary risk factors for developing atherosclerosis? o A. Family history of heart disease o B. Overweight o C. Smoking o D. Age Correct Answer: A. Family history of heart disease Family history of heart disease is an inherited risk factor that is not subject to a lifestyle change. Having a first-degree relative with heart disease has been shown to significantly increase risk. ASCVD is multifactorial etiology. The most common risk factors include hypercholesterolemia (LDL-cholesterol), hypertension, diabetes mellitus, cigarette smoking, age (male older than 45 years and female older than 55 years), male gender, and strong family history (male relative younger than 55 years and female relative younger than 65 years). o Option B: Also, a sedentary lifestyle, obesity, diets high in saturated and trans-fatty acids, and certain genetic mutations contribute to risk. While a low level o Option B: Myocardial ischemia is further exacerbated by impaired myocardial perfusion due to hypotension and tachycardia. The presenting symptoms of cardiogenic shock are variable. The most common clinical manifestations of shock, such as hypotension, altered mental status, oliguria, and cold, clammy skin, can be seen in patients with cardiogenic shock o Option C: Peripheral pulses are rapid and faint and may be irregular if arrhythmias are present. Clinical criteria include a systolic blood pressure of less than or equal to 90 mm Hg for greater than or equal to 30 minutes or support to maintain systolic blood pressure less than or equal to 90 mm Hg and urine output less than or equal to 30 mL/hr or cool extremities. 60 o A. Walk barefoot whenever possible. o B. Use a heating pad to keep feet warm. o C. Avoid crossing the legs. o D. Use antibacterial ointment to treat skin lesions at riskof infection. Correct Answer: C. Avoid crossing the legs. Patients with peripheral vascular disease should avoid crossingthe legs because this can impede blood flow. Place the client‟s legs in a dependent position in relation to the heart to improveperipheral blood flow. Keep the client in a neutral, flat, supineposition if in doubt about the nature of his peripheral vascular problems. o Option A: Walking barefoot is not advised, as foot protection is important to avoid trauma that may lead to serious infection. Randomized trials have shown supervised exercise therapy programs to have significant improvement in claudication symptoms. A meta-analysis of 27 studies found exercise significantly improved pain- free walking distance by 269 feet and total walking distance by nearly 400 feet. o Option B: Heating pads can cause injury, which can also increase the risk of infection. Never apply a directheat source to the extremities. Limited blood flow combined occurs with normal circulation. Provide insulating warmth with gloves, socks, and other outerwear as appropriate. o Option D: Skin lesions at risk for infection should be examined and treated by a physician. If overreplacement of glucocorticoid is indicated, informthe client about the purpose of therapy and possible adverse effects such as cushingoid appearance, weight gain, acne, hirsutism, peptic ulcer, diabetes mellitus, osteoporosis, infection, muscular weakness, mood swings, cataracts, and hypertension. • 49. Question 61 A patient who has been diagnosed with vasospastic disorder (Raynaud‟s disease) complains of cold and stiffness in the fingers.Which of the following descriptions is most likely to fit the patient? o A. An adolescent male o B. An elderly woman o C. A young woman o D. An elderly man Correct Answer: C. A young woman Raynaud‟s disease is most common in young women and is frequently associated with rheumatologic disorders, such as lupusand rheumatoid arthritis. Secondary Raynaud phenomenon is associated with different etiologies. It is most commonly associated with connective tissue disorders such as scleroderma, systemic lupus erythematosus, Sjogren syndrome, and antiphospholipid syndrome. o Option A: Primary Raynaud phenomenon usually occurs in the second or third decade of life, with a baseline prevalence rate of 8% in men. Occupations that result in overt vibrational exposure from vibrating machinery mostly affect males. This is known as hand-arm vibration syndrome. Exposure to polyvinyl chloride, cold injury from work, or ammunition work are other occupational-associated causes of secondaryRaynaud phenomenon. o Option B: Primary Raynaud phenomenon usually occurs in the second or third decade of life. Secondary Raynaud phenomenon occur more frequently in women (about 20% to 30%), particularly in younger age populations (teens to 20s). The female to male ratio is 9 to 1. o Option D: Primary Raynaud phenomenon occurs morefrequently in women than in men. In the population of patients older than 60 years, obstructive vascular disease is a frequent cause of the Raynaud phenomenon. Obstructive vascular disease causes 62 Correct Answer: B. Pulmonary embolism due to deep vein thrombosis (DVT). In a hospitalized patient on prolonged bed rest, the most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs. Most pulmonary embolisms originate as lower extremity DVTs. Hence, risk factors for pulmonary embolism (PE) are the same as risk factors for DVT. Virchow‟s triad of hypercoagulability, venous stasis, and endothelial injury provides an understanding of these risk factors. o Option A: Smoking and abnormal apolipoprotein ratio showed the strongest association with acute myocardial infarction. The increased risk associated with diabetes and hypertension were found to be higher in women, and the protective effect of exercise and alcohol was also found to be higher in women. o Option C: There is no reason to suspect an anxiety disorder in this patient. Pregnancy is one of the most • 50. Question A 23-year-old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which ofthe following conditions is the most likely cause of her symptoms? o A. Myocardial infarction due to a history ofatherosclerosis. o B. Pulmonary embolism due to deep veinthrombosis (DVT). o C. Anxiety attacks due to worries about her baby'shealth. o D. Congestive heart failure due to fluid overload. include thromboangiitis obliterans, microemboli, diabetic angiopathy, or atherosclerosis 65 extension, right or left tilt. These have names such as horizontaltorticollis, vertical, oblique, or torsion. o Option B: In craniosynostosis one of the cranial sutures, often the sagittal, closes prematurely, causingthe head to grow in an abnormal shape. Craniosynostosis is the result of the early fusion of cranial sutures. These sutures exist to facilitate the passage of the baby through the birth canal and later on allow the expansion and growth of the brain. When one or more sutures close prematurely, the structure of the skull becomes altered, growing on the path of least resistance (perpendicularly to the closed suture) and resulting in an atypically shaped skull leading to increased intracranial pressure (ICP) and having an effect on the respiratory and neurologic systems, as well as the development of the child. o Option C: Plagiocephaly refers to the flattening of oneside of the head, caused by the infant being placed supine in the same position over time. Plagiocephaly isdefined as an asymmetric shape of the head due to unilateral flattening. The term flathead can be used as a synonym. Plagiocephaly can be categorized into synostotic or deformational types. o Option D: Hydrocephalus is caused by a build-up of cerebrospinal fluid in the brain resulting in large head size. Hydrocephalus is the symptomatic accumulationof cerebrospinal fluid (CSF) inside the cerebral ventricles. This accumulation may be due to obstruction in the normal flow of the CSF, or to problems with absorption into the venous system by the Pacchionian arachnoid granulations, or due to excessive production of CSF. • 53. Question Anadolescent brings aphysician‟s note to school stating that heis not to participate in sports due to a diagnosis of Osgood- Schlatter disease. Which of the following statements about the disease is correct? o A. The condition was caused by the student'scompetitive swimming schedule. 66 o B. The student will most likely require surgicalintervention. o C. The student experiences pain in the inferioraspect of the knee. o D. The student is trying to avoid participation in physicaleducation. Correct Answer: C. The student experiences pain in theinferior aspect of the knee. Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer. o Option A: Swimming is not a likely cause. Osgood Schlatter disease is an overuse injury that occurs in active adolescent patients. It occurs secondary to repetitive strain and microtrauma from the force applied by the strong patellar tendon at its insertion into the relatively soft apophysis of the tibial tubercle.This force results in irritation and severe cases partial avulsion of the tibial tubercle apophysis. o Option B: The condition is usually self-limited, responding to ice, rest, and analgesics. The condition is self- limited and occurs secondary to repetitive extensor mechanism stress activities such as jumpingand sprinting. Ultimately, the condition is self-limitingbut may persist for up to 2 years until the apophysisfuses. Treatment includes relative rest and activity modification from the offending activity as guided by the level of pain. o Option D: Continued participation will worsen the condition and the symptoms. Force is increased with higher levels of activity and especially after periods of rapid growth. Rarely trauma may lead to a full avulsionfracture. Predisposing factors include poor flexibility ofquadriceps and hamstrings or other evidence of extensor mechanism malalignment. 67 • 54. Question The clinic nurse asks a 13-year-old female to bend forward at thewaist with arms hanging freely. Which of the following assessments is the nurse most likely conducting? o A. Spinal flexibility o B. Leg length disparity o C. Hypostatic blood pressure o D. Scoliosis Correct Answer: D. Scoliosis A check for scoliosis, a lateral deviation of the spine, is an important part of the routine adolescent exam. It is assessed by having the teen bend at the waist with arms dangling, while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. Evaluation is generally a screening evaluation either through a school entity, sports coach,or pediatrician. The proper formal evaluation includes x-ray imaging. o Option A: The ability to move the spine through its full range of motion, both forward and backward, demonstrates a high level of flexibility, and when donecorrectly, also good control over the spinal structure. Although the spine is made up of a chain of bones, it isflexible due to elastic ligaments and spinal disks. o Option B: Leg length disparity (discrepancy) or anisomelia, is defined as a condition in which the paired lower extremity limbs have a noticeably unequal length. Leg length discrepancy (LLD) has been a controversial issue among researchers and clinicians for many years. Its presence is accepted but there is little consensus as to its many aspects, including the extent of LLD considered to be clinically significant, the prevalence, reliability, and validity of the measuring methods, the effect of LLD on function, and its role in various neuromusculoskeletal conditions 70 Correct Answer: A. Small blue-white spots are visible on the oral mucosa. Koplik‟s spots are small blue-white spots visible on the oral mucosa and are characteristic of measles infection. Most cases • 57. Question A nonimmunized child appears at the clinic with a visible rash. Which of the following observations indicates the child may haverubeola (measles)? o A. Small blue-white spots are visible on the oralmucosa. o B. The rash begins on the trunk and spreads outward. o C. There is low-grade fever. o D. The lesions have a "teardrop on a rose petal"appearance. o Option A: The anterior fontanel is closed in a 4-year- old child. The average closure time of the anterior fontanelle ranges from 13 to 24 months. Infants of African descent statically have larger fontanelles that range from 1.4 to 4.7 cm, and in terms of sex, the fontanelles of male infants will closer sooner compared to female infants. o Option C: Evidence of sleepiness at 10 PM is normal for a four year old. Newborns spend most of their day sleeping, and they only wake up to be fed, on the other hand, 1-year-old infants sleep for 10 to 12 hours at night without waking. The coordination between biological rhythm and sleep-wake cycle develops over the first six months of life. o Option D: The average 4-year-old child cannot read yet, so this too is normal. Most children learn to read by 6 or 7 years of age. Some children learn at 4 or 5 years of age. Even if a child has a head start, she may not stay ahead once school starts. The other students most likely will catch up during the second or third grade. 71 show the characteristic Koplik spots of the disease, located in the buccal mucosa at the height of the second molar, and appear two to three days before the rash and disappear on the third day. o Option B: The body rash typically begins on the face and travels downward. The second phase, the eruptive, is characterized by the appearance of a maculopapular rash, initially fine that subsequently becomes confluent. The rash begins behind the auricleand along the hair implantation line, and extends downward to the face, trunk, and extremities. o Option C: High fever is often present. The primary orprodromal phase lasts four to six days and is characterized by the presence of high fever, malaise, coryza, conjunctivitis, palpebral edema, and dry cough. o Option D: “Teardrop on a rose petal” refers to the lesions found in varicella (chickenpox). The characteristic chickenpox vesicle, surrounded by an erythematous halo, is described as a dewdrop on a rose petal. Chickenpox is clinically characterized by the presence of active and healing lesions in all stagesof development within affected locations. Lesions characteristically heal without scarring, although excoriation or secondary bacterial superinfection predisposes to scar formation. • 58. Question A child is seen in the emergency department for scarlet fever. Which of the following descriptions of scarlet fever is not correct? o A. Scarlet fever is caused by infection with group AStreptococcus bacteria. o B. "Strawberry tongue" is a characteristic sign. o C. Petechiae occur on the soft palate. o D. The pharynx is red and swollen. Correct Answer: C. Petechiae occur on the soft palate. 72 Petechiae on the soft palate are characteristic of rubella infection.Postnatal infection with rubella can be asymptomatic in approximately 25% to 50% of the patients, especially in young children. The incubation period ranges from 14 to 21 days and is followed by a prodromal illness characterized by low-grade fever, malaise, anorexia, headaches, sore throat, and adenopathy. o Option A: It is caused by streptococcal pyrogenic exotoxins (SPEs) types A, B, and C produced by groupA beta- hemolytic streptococci (GABHS) found in secretions and discharge from the nose, ears, throat, and skin. The causative bacteria is Streptococcus pyogenes, which generates an endotoxin mainly responsible for the skin manifestation of the infection.This is further classified as group A and referred to asGroup A Strep (GAS). o Option B: On day 1 or 2, the tongue is heavily coatedwith a white membrane through which edematous red papillae protrude (classic appearance of white strawberry tongue). By day 4 or 5, the white membrane sloughs off, revealing a shiny red tongue with prominent papillae (red strawberry tongue). o Option D: Red, edematous, exudative tonsils are typically observed if the infection originates in this area. Typically, scarlet fever is associated with acutepharyngitis. As a result, fever, sore throat, pain withswallowing, and cervical adenopathy is present. • 59. Question A child weighing 30 kg arrives at the clinic with diffuse itching asthe result of an allergic reaction to an insect bite. diphenhydramine (Benadryl) 25 mg 3 times a day is prescribed. The correct pediatric dose is 5 mg/kg/day. Which of thefollowing best describes the prescribed drug dose? o A. It is the correct dose. o B. The dose is too low. o C. The dose is too high. 75 • 61. Question Mrs. Chua, a 78-year-old client, is admitted with the diagnosis of mild chronic heart failure. The nurse expects to hear when listening to client‟s lungs indicative of chronic heart failure wouldbe: o A. Stridor o B. Crackles o C. Wheezes o D. Friction rubs Correct Answer: B. Crackles Left-sided heart failure causes fluid accumulation in the capillary network of the lung. Fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration. Pulmonary edema may cause crackling sounds in the lungs. People with congestive heart failure (CHF) often have pulmonary edema. CHF occurs when the heart cannot pump blood effectively. This resultsin a backup of blood, which increases blood pressure and causes fluid to collect in the air sacs in the lungs. o Option A: Stridor may result from lesions involving the central nervous system (CNS), the cardiovascular system, the gastrointestinal (GI) tract, or the respiratory tract. When air passes through a narrowedflexible airway in a child, the lateral pressure that holds the airway open can drop precipitously (the Bernoulli principle) and cause the tube to close. This process obstructs airflow and produces stridor. o Option C: The most common causes of wheezing are asthma and chronic obstructive pulmonary disease (COPD), which both cause narrowing and spasms (bronchospasms) in the small airways of the lungs. However, any inflammation in the throat or larger airways can cause wheezing. Common causes includeinfection, an allergic reaction or a physical obstruction, scrotum with an orchiopexy starting at age six months. 76 • 62. Question Patrick who is hospitalized following a myocardial infarction asksthe nurse why he is taking morphine. The nurse explains that morphine: o A. Decrease anxiety and restlessness o B. Prevents shock and relieves pain o C. Dilates coronary blood vessels o D. Helps prevent fibrillation of the heart o Option A: Benzodiazepines decrease anxiety and restlessness. Indications for benzodiazepine administration include, but are not limited to, anxiety disorders, insomnia, acute status epilepticus, induction of amnesia, spastic disorders, seizure disorders, and agitation. o Option C: Calcium channel blockers, such as nitroglycerin, dilate large coronary blood vessels. The dihydropyridines, in therapeutic dosing, have a little direct effect on the myocardium, and instead, are more often peripheral vasodilators, which is why they Correct Answer: B. Prevents shock and relieves pain Morphine is a central nervous system depressant used to relieve the pain associated with myocardial infarction, it also decreases apprehension and prevents cardiogenic shock. FDA-approved usage of morphine sulfate includes moderate to severe pain that may be acute or chronic. Most commonly used in pain management, morphine provides major relief to patients afflicted with pain. such as a tumor or a foreign object that‟s been inhaled. o Option D: A pericardial friction rub is pathognomonic for acute pericarditis; the rub has a scratching, grating sound similar to leather rubbing against leather. Serial examinations may be necessary for detection, as a friction rub may be transient from one hour to the next and is present in approximately 50% of cases. 77 o Option A: GI symptoms of digitalis toxicity include anorexia and weight loss. Most symptoms are nonspecific findings and include a headache, malaise, insomnia, altered mental status, abdominal pain, nausea, and vomiting. o Option B: Hypotension is one of the cardiac symptoms of digitalis toxicity. There is no specific arrhythmia for digoxin toxicity rather a range of arrhythmias can be present such as various degrees of AV block, premature ventricular contractions, bradycardia, and even ventricular tachycardia. Cardiac Correct Answer: D. Visual disturbances such as seeing yellow spots Seeing yellow spots and colored vision are common symptoms of digitalis toxicity. Of note visual changes especially changes involving colors such as seeing a yellow hue are better known and specifically seen in digitalis toxicity. Other visual problems include photophobia, photopsia and diminished visual acuity. • 63. Question Which of the following should the nurse teach the client about thesigns of digitalis toxicity? o A. Increased appetite o B. Elevated blood pressure o C. Skin rash over the chest and back o D. Visual disturbances such as seeing yellow spots are useful for hypertension, post-intracranial hemorrhage associated vasospasm, and migraines. o Option D: Antiplatelets and anticoagulants help prevent atrial fibrillation by preventing blood clot formation. Antiplatelet medications divide into oral and parenteral agents. Oral agents subdivide further based on the mechanism of action. Aspirin was the first antiplatelet medication and is a cyclooxygenase inhibitor. 80 Correct Answer: C. Extension of the extremities after a stimulus Decerebrate posturing is the extension of the extremities after a stimulus which may occur with upper brain stem injury. Decerebrate posturing is described as adduction and internal rotation of the shoulder, extension at the elbows with pronation of the forearm, and flexion of the fingers. o Option A: Decerebrate posturing is the extension, not flexion, of extremities. As with decorticate posturing, the lower limbs show extension and internal rotation • 66. Question Nurse Linda is caring for a client with head injury and monitoring the client with decerebrate posturing. Which of the following is a characteristic of this type of posturing? o A. Upper extremity flexion with lower extremity flexion o B. Upper extremity flexion with lower extremityextension o C. Extension of the extremities after a stimulus o D. Flexion of the extremities after stimulus saturation at greater than 90%. Any associated arrhythmia or MI should be treated appropriately. o Option C: Respiratory status would improve following an increase in the cardiac output. Patients who remain hypoxic despite supplemental oxygenation and patients who have severe respiratory distress require ventilatory support in addition to maximal medical therapy. o Option D: Peripheral edema is a manifestation of cardiogenic pulmonary edema and right ventricular heart failure, but it is not a primary concern. In general, begin with oral vasodilator therapy, most commonly ACE inhibitors. If the patient was initially treated with inotropic medications, wean the patient off of these as soon as his or her condition is stable, to minimize adverse effects. 81 o Option A: There is no GI bleeding associated with Cascara sagrada. Cascara sagrada is possibly unsafe when used for more than one week. This could cause more serious side effects including dehydration; low levels of potassium, sodium, chloride, and other Correct Answer: C. Abdominal cramps The most frequent side effects of Cascara Sagrada (Laxative) is abdominal cramps and nausea. Cascara sagrada is possibly safe for most adults when taken for less than one week. Side effects include stomach discomfort and cramps. • 67. Question A female client is taking Cascara Sagrada. Nurse Betty informs the client that the following may be experienced as side effects ofthis medication: o A. GI bleeding o B. Peptic ulcer disease o C. Abdominal cramps o D. Partial bowel obstruction at the hip, with the extension of the knee and plantar flexion of the feet. Toes are typically abducted and hyperextended. o Option B: The upper extremity should be in extension as well as the lower extremity. Decerebrate posturing can be seen in patients with large bilateral forebrain lesions with progression caudally into the diencephalon and midbrain. It can also be caused by a posterior fossa lesion compressing the midbrain or rostral pons. o Option D: There is an extension of extremities after a stimulus in decerebrate posturing. Teasdale and Jennett advocated not using the term „decerebrate‟ in the assessment of coma due to its association with a specific physio anatomical correlation, but to rather use the term „extension.‟ 82 Correct Answer: D. Obtaining infusion pump for the medication Administration of Intravenous nitroglycerin infusion requires a pump for accurate control of medication. There are intravenous (IV) routes of administration for nitroglycerin used most commonly in emergency rooms and intensive care units (ICU). It is administered as a 5% dextrose in water drip and is indicated when sublingual nitroglycerin has failed to provide symptomatic relief or if rapid and continued relief of symptoms is necessary. When administered, its effect requires tight monitoring, as discussed below. • 68. Question Dr. Marquez orders a continuous intravenous nitroglycerin infusion for the client suffering from myocardial infarction. Whichof the following is the most essential nursing action? o A. Monitoring urine output frequently o B. Monitoring blood pressure every 4 hours o C. Obtaining serum potassium levels daily o D. Obtaining infusion pump for the medication “electrolytes” in the blood; heart problems; muscle weakness; and others. o Option B: Peptic ulcer disease is not a side effect of Cascara sagrada, however, stomach discomfort may occur when using this drug. Gastrointestinal (GI) disorders such as intestinal obstruction, Crohn disease, ulcerative colitis, appendicitis, stomach ulcers, or unexplained stomach pain: people with any of these conditions should not use cascara sagrada. o Option D: Partial bowel obstruction is not associated with the use of Cascara sagrada. Cascara is a type of laxative called a stimulant laxative. Stimulant laxatives speed up the bowels. Taking cascara along with other stimulant laxatives could speed up the bowels too much and cause dehydration and low minerals in the body. 85 o B. Use hand roll and extend the left upperextremity on a pillow to prevent contractions o C. Use a bed cradle to prevent dorsiflexion of feet o D. Do passive range of motion exercise Correct Answer: B. Use hand roll and extend the left upper extremity on a pillow to prevent contractions The left side of the body will be affected in a right-sided brain attack. Begin active or passive ROM to all extremities (includingsplinted) on admission. Encourage exercises such as quadriceps/glutes exercise, squeezing rubber ball, extension of fingers and legs/feet. Minimizes muscle atrophy, promotes circulation, helps prevent contractures. Reduces risk of hypercalciuria and osteoporosis if the underlying problem is hemorrhage. o Option A: The left upper extremity will be affected, application of elastic stockings is unnecessary. Assist the patient with exercise and perform ROM exercises for both the affected and unaffected sides. Teach andencourage the patient to use his unaffected side to exercise his affected side. ROM exercise helps in reducing muscle stiffness and spasticity. It can also help prevent contractures. o Option C: There is no dorsiflexion of foot in a right- sided brain attack. Prop extremities in functional position; use footboard during the period of flaccid paralysis. Maintain a neutral position of the head. Prevents contractures and foot drop and facilitates usewhen function returns. Flaccid paralysis may interfere with ability to support the head, whereas spastic paralysis may lead to deviation of the head to one side. o Option D: Active-assistive range of motion exercises would be recommended for the client. Encourage the patient to assist with movement and exercises using unaffected extremity to support and move the weaker side. May respond as if the affected side is no longerpart of the bodyand needs encouragement and activetraining to “reincorporate” it as a part of own body. 86 • 71. Question Nurse Liza is assigned to care for a client who has returned to thenursing unit after left nephrectomy. Nurse Liza‟s highest priority would be… o A. Hourly urine output o B. Temperature o C. Able to turn side to side o D. Able to sips clear liquid Correct Answer: A. Hourly urine output After nephrectomy, it is necessary to measure urine output hourly. This is done to assess the effectiveness of the remainingkidney also to detect renal failure early. Immediately after surgery, the health care team will carefully watch the client‟s blood pressure, electrolytes and fluid balance. These body functions are controlled in part by the kidneys. The client will most likely have a urinary catheter (tube to drain urine) in the bladder for a short time during the recovery. o Option B: Monitoring temperature regularly is recommended, but not the highest priority. The clientmay have discomfort and numbness (caused by severed nerves) near the incision area. Pain relievers are given after the surgical procedure and during therecovery period as needed. Although deep breathing and coughing may be painful because the incision is close to the diaphragm, breathing exercises are important to prevent pneumonia. o Option C: The client would be able to turn to his sideswith some assistance after surgery. The client will probably remain in the hospital for 1 to 7 days, depending on the method of surgery used. He will beencouraged to return to light activities as soon as hefeels up to it. Strenuous activity and heavy lifting should be avoided for 6 weeks following the procedure. 87 • 72. Question A 64-year-old male client with a long history of cardiovascular problems including hypertension and angina is to be scheduled for cardiac catheterization. During pre-cardiac catheterization teaching, Nurse Cherry should inform the client that the primarypurpose of the procedure is: o A. To determine the existence of CHD. o B. To visualize the disease process in the coronaryarteries. o C. To obtain the heart chambers pressure. o D. To measure oxygen content of different heartchambers. Correct Answer: B. To visualize the disease process in the coronary arteries. The lumen of the arteries can be assessed by cardiac catheterization. Angina is usually caused by narrowing of the coronary arteries. Left heart catheterization has a diagnostic as well as therapeutic role. Although it is used for cardiac hemodynamics and assessment of valvular lesions, its main diagnostic role is the assessment of coronary artery disease. In the contemporary era, left heart catheterization, especially o Option D: The client would be allowed to take sips of clear liquid as recommended by the physician. The doctor will give the client more detailed instructions about post-operative activities, restrictions and diet. Tests will be done on a regular basis to check how well the remaining kidney is working. A urinalysis (urine test) and blood pressure check should be done every year, and kidney function tests (creatinine, glomerular filtration rate [GFR]) should be checked every few years (or more often if abnormal results are found). Regular urine tests for protein should be performed as well. The presence of protein in the urine may mean that the kidney has some damage. 90 • 74. Question Kate, who has undergone mitral valve replacement, suddenly experiences continuous bleeding from the surgical incision duringthe postoperative period. Which of the following pharmaceutical agents should Nurse Aiza prepare to administer to Kate? o A. Protamine Sulfate o B. Quinidine Sulfate o C. Vitamin C o D. Coumadin Correct Answer: A. Protamine Sulfate Protamine Sulfate is used to prevent continuous bleeding in a client who has undergone open heart surgery. Protamine is a medication used to reverse and neutralize the anticoagulant effects of heparin. Protamine is the specific antagonist that neutralizes heparin-induced anticoagulation. Protamine is a strongly alkaline (nearly two-thirds of the amino acid compositionis arginine) polycationic low-molecular- weight protein found in salmon sperm that is also currently available in a recombinant form. o Option B: Quinidine sulfate is used to treat or preventmany types of irregular heartbeats such as atrial fibrillation. Quinidine can greatly improve the ability toperform normal activities by decreasing the number of irregular heartbeats. However, it may not stop all irregular heartbeats completely. It works by blocking abnormal heartbeat signals. o Option C: Vitamin C, or ascorbic acid, has several important functions: helping to protect cells and keeping them healthy, maintaining healthy skin, bloodvessels, bones, and cartilage, and helping with wound healing. o Option D: Coumadin is used to treat blood clots and/or prevent new clots from forming in the body. Preventing harmful blood clots helps to reduce the riskof a stroke or heart attack. Conditions that increase 91 • 75. Question In reducing the risk of endocarditis, good dental care is an important measure. To promote good dental care in clients with endocarditis in a teaching plan should include proper use of? o A. Dental floss o B. Electric toothbrush o C. Manual toothbrush o D. Irrigation device Correct Answer: C. Manual toothbrush The use of an electric toothbrush, irrigation device or dental flossmay cause bleeding of gums, allowing bacteria to enter and increasing the risk of endocarditis. Maintaining good oral hygieneand infection control can decrease the incidence of endocarditis in the moderate- risk group of patients and can eliminate the necessity of antibiotic prophylaxis of endocarditis. o Option A: Dental floss may injure the gums and causebleeding that may lead to infection. The gums become inflamed (red and swollen) and often bleed during tooth brushing, flossing, or certain dental procedures involving manipulation of the gums. When gums bleed, the bacteria can enter the bloodstream and can infect other parts of the body. o Option B: Electronic toothbrushes cause too muchfriction to the gums and cause an infection that can increase the risk of endocarditis. In very rare cases, bacteria in the mouth may trigger endocarditis in people at higher risk. Here‟s what happens: Bacteriafound in tooth plaque may multiply and cause gingivitis (gum disease). o Option D: An irrigation device uses a stream of pressurized, pulsating water to clean between teeth the risk of developing blood clots include a certain type of irregular heart rhythm (atrial fibrillation), heart valve replacement, recent heart attack, and certain surgeries (such as hip/knee replacement). 92 and below the gum line. The water‟s pressure may cause injury to sensitive gums and lead to bleeding or an infection. To prevent endocarditis, patients with certain heart conditions receive a single dose of an antibiotic. The patient receives it about one hour prior to certain dental treatments.