NCLEX- RN Practice Exam 1

EXPLANATION

 

✔ Correct answer:

Probable anorexia nervosa: The girl's symptoms, including an inability to eat, self-induced vomiting, and severe constipation, combined with a low BMI of 18, strongly suggest anorexia nervosa. Anorexia nervosa is an eating disorder characterized by an intense fear of gaining weight, a distorted body image, and extreme restriction of food intake, leading to significant weight loss and malnutrition. The behaviors of self-induced vomiting and resulting gastrointestinal issues like severe constipation are also consistent with this diagnosis.

Think of the body as a car that needs fuel (food) to run. Anorexia nervosa is like refusing to put fuel in the car because of a fear that the car will get too heavy. Without fuel, the car (body) can't function properly, leading to a breakdown in systems like digestion.

Anorexia nervosa is a serious mental health condition that requires a multidisciplinary approach for treatment, including medical, nutritional, and psychological support. It can lead to severe complications such as electrolyte imbalances, cardiac issues, and multi-organ failure if not addressed promptly. Early intervention and a comprehensive treatment plan are crucial for recovery.

 

✘ Incorrect answer options:

Potential systemic sclerosis: Systemic sclerosis (scleroderma) is an autoimmune disease that causes hardening and tightening of the skin and connective tissues. It does not typically present with symptoms of self-induced vomiting or an inability to eat due to fear of gaining weight.

Possible bulimia: Bulimia nervosa involves episodes of binge eating followed by compensatory behaviors such as vomiting, but individuals with bulimia often maintain a normal weight or are slightly overweight. The reported BMI of 18 is more indicative of anorexia nervosa.

Likely multiple sclerosis: Multiple sclerosis (MS) is a neurological disorder affecting the central nervous system, characterized by symptoms such as fatigue, motor weakness, and vision problems. It is not associated with the eating behaviors and gastrointestinal symptoms described in this case.

 

References

• American Psychiatric Association. (2013). *Diagnostic and Statistical Manual of Mental Disorders (5th ed.).* American Psychiatric Publishing.
• Golden, N. H., & Katzman, D. K. (2017). *Eating Disorders in Adolescents: Position Paper of the Society for Adolescent Medicine.* Journal of Adolescent Health, 24(5), 433-442.

EXPLANATION

 

✔Correct answer:

CT scan. Given the patient's symptoms of increased confusion, recent falls, and mild left hemiparesis, a CT scan of the head is the most appropriate diagnostic test to prioritize. These symptoms suggest a possible acute neurological event such as a stroke, transient ischemic attack (TIA), or other brain pathology (e.g., a subdural hematoma). A CT scan can quickly and accurately identify or rule out such conditions, which require prompt diagnosis and intervention to prevent further deterioration and to initiate appropriate treatment.

Think of the CT scan as a detective's magnifying glass. When there is suspicion of a serious problem like a stroke, the CT scan helps to quickly zoom in and provide a clear picture of what is happening inside the brain, allowing for immediate and targeted action.

In elderly patients presenting with sudden neurological changes, time is critical. A CT scan is a non-invasive, rapid imaging technique that provides detailed images of the brain. It is especially valuable in acute settings to detect bleeding, ischemic changes, or other structural abnormalities. Early identification of these issues is crucial for determining the appropriate medical or surgical intervention and improving patient outcomes. Nurses play a key role in recognizing the signs and symptoms of acute neurological events and ensuring timely diagnostic evaluation.

 

✘Incorrect answer options:

Thyroid function tests. While thyroid dysfunction can cause cognitive changes, it is less likely to be the immediate cause of acute neurological symptoms like hemiparesis. Thus, it is not the priority test in this context.

ECG (electrocardiogram). An ECG is useful for evaluating cardiac function and could be part of a comprehensive workup, especially if there are signs of arrhythmia or cardiac ischemia, but it is not the first-line diagnostic test for acute neurological symptoms.

FBC (full blood count). A full blood count can provide useful information about the patient’s general health and detect issues such as infection or anemia, but it is not the primary diagnostic tool for acute neurological symptoms like hemiparesis and confusion.

 

References

• Lehne, R. A., Moore, L. K., Crosby, L., & Hamilton, D. (2019). Pharmacology for Nursing Care. Elsevier.
• Ignatavicius, D. D., & Workman, M. L. (2020). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.

EXPLANATION

 

✔Correct answers:

When barbiturates are discontinued, REM sleep increases. Upon discontinuation of barbiturates, there is a rebound increase in REM sleep. This is because barbiturates suppress REM sleep during use, and the body compensates by increasing REM sleep once the drug is stopped.

Barbiturates deprive people of REM sleep. Barbiturates are known to suppress REM sleep, which is the phase of sleep associated with dreaming and important for cognitive function and emotional regulation.

Nightmares are often an adverse effect when discontinuing barbiturates. The rebound increase in REM sleep after discontinuing barbiturates can lead to intense and vivid dreams or nightmares as the body attempts to recover the lost REM sleep.

Think of barbiturates like putting a pause on your favorite TV show (REM sleep). While the show is paused, you miss out on the episodes (REM sleep). When you finally resume watching, you try to catch up by watching a lot at once, leading to a binge-watching session (REM rebound with vivid dreams).

Understanding the effects of barbiturates on sleep architecture is crucial for managing patients with insomnia and those who are discontinuing these medications. Barbiturates' suppression of REM sleep can affect cognitive function and mood. Nurses must be aware of the potential for REM rebound and associated adverse effects like nightmares, which can occur when barbiturates are stopped. Patient education and monitoring during the discontinuation period are essential for managing these effects.

 

✘Incorrect answer options:

When barbiturates are discontinued, NREM sleep increases. Discontinuation of barbiturates typically leads to a rebound increase in REM sleep rather than NREM sleep.

Barbiturates deprive people of NREM sleep. Barbiturates primarily affect REM sleep rather than NREM sleep. They may have some effect on sleep stages within NREM, but their main impact is on reducing REM sleep.

 

References

• Lehne, R. A., Moore, L. K., Crosby, L., & Hamilton, D. (2019). Pharmacology for Nursing Care. Elsevier.
• Ignatavicius, D. D., & Workman, M. L. (2020). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.

EXPLANATION

 

✔ Correct answer:

Clostridium difficile (Cl. difficile): Clostridium difficile (C. difficile) is not associated with causing meningitis in humans. C. difficile is a bacterium that primarily affects the gastrointestinal tract, leading to conditions such as antibiotic-associated diarrhea and pseudomembranous colitis. It does not cause meningitis, which is an inflammation of the protective membranes covering the brain and spinal cord.

Think of the human body as a city with different districts. C. difficile causes issues in the digestive district (gastrointestinal tract), while meningitis occurs in the central district (central nervous system). These two districts are not directly connected by the same types of infections.

Meningitis can be caused by various microorganisms, including bacteria, viruses, fungi, and parasites. The most common bacterial causes of meningitis include Haemophilus influenzae, Streptococcus pneumoniae, and Neisseria meningitidis, all of which can invade the central nervous system and lead to severe inflammation. Identifying and understanding the specific pathogens that cause meningitis is crucial for effective diagnosis, treatment, and prevention.

 

✘ Incorrect answer options:

Haemophilus influenzae (H. influenza): H. influenzae, particularly type b (Hib), was once a leading cause of bacterial meningitis in children before the widespread use of the Hib vaccine.

Streptococcus pneumoniae (S. pneumonia): S. pneumoniae is a major cause of bacterial meningitis in both children and adults. It can also cause other serious infections such as pneumonia and septicemia.

Neisseria meningitidis (N. meningitidis): N. meningitidis is a leading cause of bacterial meningitis, especially in adolescents and young adults. It can cause outbreaks and has several serogroups that can be targeted by vaccines.

 

References

• van de Beek, D., de Gans, J., Tunkel, A. R., & Wijdicks, E. F. M. (2006). *Community-acquired bacterial meningitis in adults.* New England Journal of Medicine, 354(1), 44-53.
• Centers for Disease Control and Prevention (CDC). (2020). *Meningitis.* Retrieved from https://www.cdc.gov/meningitis/index.html

EXPLANATION

 

✔Correct answers:

If unable to aspirate blood, reposition the client and encourage the client to cough. Repositioning the client or encouraging them to cough can help resolve issues with blood aspiration due to positional occlusion of the catheter.

Confirm the line's patency by checking for blood return at regular intervals. Regularly checking for blood return ensures that the central venous line is patent and functioning correctly, which is crucial for the safe administration of chemotherapy.

Consult the healthcare provider to verify placement if the line's status is questionable. If there is any doubt about the placement or function of the central line, consulting the healthcare provider is necessary to avoid potential complications or misadministration of medications.

Examine the insertion site for any signs of swelling, erythema, or drainage. Regularly inspecting the insertion site for signs of infection or complications is a critical aspect of central line care to prevent serious infections and ensure the line remains safe for use.

Think of the central venous line like a crucial delivery pipeline. Just as you would check a pipeline for blockages, leaks, or damage before using it to transport essential supplies, nurses must ensure the central line is patent, correctly positioned, and free from infection before administering chemotherapy.

Proper management of central venous lines is essential in oncology nursing to ensure the safe and effective delivery of chemotherapy. This includes regularly verifying line patency, inspecting for signs of infection, and addressing any issues with blood return promptly. Adhering to these protocols helps minimize the risk of complications and ensures the best possible outcomes for patients undergoing chemotherapy.

 

✘Incorrect answer option:

Administer the chemotherapy agent as scheduled, even if blood return is absent. This statement is incorrect because administering chemotherapy without confirming blood return can be dangerous. The absence of blood return may indicate catheter occlusion or misplacement, which could result in the chemotherapy agent being delivered to the wrong location, potentially causing harm.

 

References

• Lehne, R. A., Moore, L. K., Crosby, L., & Hamilton, D. (2019). Pharmacology for Nursing Care. Elsevier.
• Ignatavicius, D. D., & Workman, M. L. (2020). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.

EXPLANATION

 

✔ Correct answer:

Possibly Aspirin: Aspirin is an anti-inflammatory and antiplatelet medication that is not typically associated with causing urine discoloration. While it can have side effects, changes in urine color are not commonly linked to aspirin use. Therefore, it should be considered irrelevant to the symptom of urine discoloration.

Imagine your urine as a clear stream. Certain medications can act like food coloring, changing the color of the stream. Aspirin, however, is like a plain white pebble that doesn’t affect the color at all.

Evaluating the potential side effects of medications is crucial in clinical practice. Understanding which medications are likely to cause certain symptoms helps in accurate diagnosis and appropriate management of patient concerns. Medications that do cause urine discoloration often do so due to their metabolic byproducts being excreted in the urine, leading to various color changes.

 

✘ Incorrect answer options:

Definitely Phenolphthalein: Phenolphthalein, a laxative, can cause urine to turn pink or red, especially in alkaline urine conditions.

Likely Sulfasalazine: Sulfasalazine is known to cause orange-yellow discoloration of the urine due to its metabolites.

Potentially Levodopa: Levodopa, used in the treatment of Parkinson's disease, can cause darkening of urine, turning it reddish, brown, or black due to the formation of melanin-like pigments.

 

References

• Brunton, L. L., Hilal-Dandan, R., & Knollmann, B. C. (2018). *Goodman & Gilman's: The Pharmacological Basis of Therapeutics.* McGraw-Hill Education.
• Tatro, D. S. (2017). *Drug Interaction Facts.* Wolters Kluwer.

EXPLANATION

 

✔ Correct answer:

The effects of PKU can be reversed: Phenylketonuria (PKU) is a genetic disorder that results in the inability to metabolize phenylalanine, leading to its accumulation in the body. If left untreated, this can cause severe mental deficits and other neurological issues. While early diagnosis and a strict dietary management can prevent these symptoms, the effects of PKU that have already occurred cannot be reversed. Thus, stating that the effects can be reversed is incorrect.

Think of PKU as a leaky faucet that can cause water damage (mental deficits) if not fixed. You can prevent more damage by fixing the leak (managing the diet), but you can't undo the damage that has already been done.

PKU requires lifelong management with a diet low in phenylalanine to prevent the buildup of harmful levels in the blood and brain. Newborn screening, such as the Guthrie test, allows for early detection and intervention, significantly reducing the risk of severe outcomes. However, once damage has occurred due to unmanaged PKU, it cannot be reversed, highlighting the importance of early and continuous dietary management.

 

✘ Incorrect answer options:

Mental deficits can commonly occur with PKU: This is correct. Without treatment, PKU can lead to severe intellectual disability and other neurological problems.

The urine exhibits a high concentration of phenylpyruvic acid: This is correct. The accumulation of phenylalanine in the body leads to the presence of phenylpyruvic acid in the urine, which is a hallmark of PKU.

A Guthrie test can determine the necessary lab values: This is correct. The Guthrie test is a newborn screening test used to detect elevated levels of phenylalanine in the blood, facilitating early diagnosis and treatment of PKU.

 

References

• Blau, N., van Spronsen, F. J., & Levy, H. L. (2010). *Phenylketonuria.* The Lancet, 376(9750), 1417-1427.
• National Institutes of Health. (2000). *Phenylketonuria: Screening and Management.* NIH Consensus Statement, 17(3), 1-33.

EXPLANATION

 

✔Correct answers:

Has a duration of normally 0.11 seconds or less.  The P wave represents atrial depolarization and normally lasts for 0.11 seconds or less. This short duration is due to the rapid conduction of the electrical impulse through the atria.

Reflects electrical impulse beginning at the SA node. The P wave is generated by the electrical impulse that originates at the sinoatrial (SA) node, which is the natural pacemaker of the heart. This impulse travels through the atria, causing them to depolarize and contract.

Reflects atrial muscle depolarization. The primary function of the P wave is to reflect the depolarization of the atrial muscles. This electrical activity leads to the contraction of the atria, pushing blood into the ventricles.

Think of the P wave as the starting whistle in a race. It signals the beginning of the action (atrial depolarization), just as the whistle signals the start of the runners. The duration of the whistle is short, much like the P wave's duration is less than 0.11 seconds.

Understanding the characteristics of the P wave is essential for accurately interpreting ECGs and diagnosing cardiac rhythms. Recognizing that the P wave signifies atrial depolarization starting from the SA node helps nurses identify normal sinus rhythm and detect any atrial abnormalities. Proper interpretation of the P wave, along with other ECG components, enables timely and appropriate interventions for cardiac conditions.

 

✘Incorrect answer options:

Identifies ventricular muscle depolarization. This statement is incorrect because the P wave represents atrial depolarization, not ventricular depolarization. Ventricular depolarization is represented by the QRS complex on an ECG.

Indicates electrical impulse beginning at the AV node. This statement is incorrect because the P wave is generated by the impulse originating from the SA node, not the AV node. The AV node is involved in the PR interval and the subsequent conduction to the ventricles.

 

References

• Lehne, R. A., Moore, L. K., Crosby, L., & Hamilton, D. (2019). Pharmacology for Nursing Care. Elsevier.
• Ignatavicius, D. D., & Workman, M. L. (2020). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.

EXPLANATION

 

✔ Correct answer:

From the moment of admittance: Discharge planning should begin from the moment of admittance. Early initiation of discharge planning ensures that all necessary arrangements, education, and support systems are in place to facilitate a smooth transition from hospital to home or another care setting. It allows for a comprehensive assessment of the patient’s needs, including potential challenges they may face post-surgery, and ensures that appropriate resources and instructions are provided.

Think of discharge planning like preparing for a long trip. You start packing and making arrangements well before the departure date to ensure everything goes smoothly. Similarly, starting discharge planning early helps ensure a seamless and safe transition for the patient.

Early discharge planning involves interdisciplinary collaboration, including physicians, nurses, physical therapists, social workers, and other healthcare professionals, to address the patient’s medical, physical, and psychosocial needs. This approach helps to identify and mitigate potential barriers to recovery, reduces the risk of readmission, and promotes patient satisfaction and outcomes.

 

✘ Incorrect answer options:

Within 48 hours prior to discharge: This time frame is too short to address all aspects of discharge planning adequately. It may result in incomplete preparation and potential complications post-discharge.

Immediately after the surgery is completed: While discharge planning continues post-surgery, it should not start at this point. Planning should be an ongoing process beginning at admission to ensure all necessary preparations are made.

During the preoperative discussion: Although discussing discharge plans preoperatively is beneficial, comprehensive discharge planning should start at admission to ensure a thorough and coordinated approach throughout the patient’s hospital stay.

 

References

• Bixby, M. B., & Konicek, D. (2014). *The impact of early discharge planning on reducing readmissions.* Professional Case Management, 19(6), 252-262.
• Weiss, M. E., Yakusheva, O., & Bobay, K. L. (2010). *Quality and cost analysis of nurse staffing, discharge preparation, and postdischarge utilization.* Health Services Research, 46(5), 1473-1494.

EXPLANATION

 

✔Correct answer:

Increased appetite. Meningitis, an inflammation of the protective membranes covering the brain and spinal cord, typically presents with symptoms that reflect central nervous system irritation and systemic infection. Common symptoms during an acute episode of meningitis include photophobia (sensitivity to light), episodes of vomiting, and elevated fever due to the body's response to infection. Increased appetite is not a symptom associated with meningitis. In fact, patients with acute meningitis often experience a decreased appetite due to systemic illness and nausea.

Think of meningitis as a computer virus that disrupts the normal functioning of a computer system. Just as a virus causes the computer to slow down, freeze, and exhibit errors (representing fever, vomiting, and photophobia), it would not cause the computer to suddenly perform tasks more efficiently or quickly (increased appetite). Similarly, meningitis causes the body to exhibit signs of distress and malfunction but not increased hunger.

Recognizing the classic symptoms of meningitis is critical for prompt diagnosis and treatment. Photophobia and vomiting are due to the irritation of the meninges and increased intracranial pressure. Fever is a common response to infection. Nurses must also be vigilant for other signs such as neck stiffness, severe headache, and altered mental status. Early intervention can significantly reduce the risk of complications and improve patient outcomes.

 

✘Incorrect answer options:

Sensitivity to light. Sensitivity to light, or photophobia, is a common symptom of meningitis due to irritation of the meninges.

Episodes of vomiting. Vomiting occurs frequently in meningitis due to increased intracranial pressure and systemic infection.

Elevated fever. Elevated fever is a hallmark of meningitis as the body's immune response to infection involves raising the body's temperature.

 

References

• Lehne, R. A., Moore, L. K., Crosby, L., & Hamilton, D. (2019). Pharmacology for Nursing Care. Elsevier.
• Ignatavicius, D. D., & Workman, M. L. (2020). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.

EXPLANATION

 

✔ Correct answer:

Likely hypercalcemia: Hypercalcemia is a condition characterized by elevated levels of calcium in the blood. The patient's symptoms of confusion, constipation, intense abdominal pain, and polyuria are classic signs of hypercalcemia. Additionally, myeloma (multiple myeloma) is often associated with hypercalcemia due to increased bone resorption, releasing excess calcium into the bloodstream. This combination of symptoms and medical history strongly suggests hypercalcemia.

Think of the body as a machine that requires balanced levels of minerals to function properly. Too much calcium in the bloodstream is like having an overload of one particular part, causing the machine to malfunction, leading to symptoms like confusion and digestive issues.

Hypercalcemia can result from various conditions, but in the context of multiple myeloma, it is usually due to excessive bone breakdown. The elevated calcium levels affect various body systems, leading to neurological symptoms (confusion), gastrointestinal symptoms (constipation, abdominal pain), and renal symptoms (polyuria). Prompt diagnosis and treatment are crucial to prevent severe complications such as kidney failure and cardiac arrhythmias.

 

✘ Incorrect answer options:

Possible irritable bowel syndrome: Irritable bowel syndrome (IBS) primarily affects the gastrointestinal tract, causing symptoms like abdominal pain, bloating, and changes in bowel habits. It does not typically cause confusion or polyuria.

Potential hypocalcemia: Hypocalcemia is characterized by low levels of calcium in the blood and presents with symptoms such as muscle cramps, tingling, and tetany. It does not explain the confusion and polyuria seen in this patient.

Probable diverticulosis: Diverticulosis involves the formation of diverticula in the colon and can cause abdominal pain and changes in bowel habits, but it does not account for the confusion and polyuria. It is not typically associated with hypercalcemia.

 

References

• Ralston, S. H., & Fraser, W. D. (2019). *Diagnosis and management of hypercalcemia.* BMJ, 364, l265.
• Kyle, R. A., & Rajkumar, S. V. (2004). *Multiple myeloma.* New England Journal of Medicine, 351(18), 1860-1873.

EXPLANATION

 

✔ Correct answer:

RH negative mothers with an RH positive infant: RhoGAM (Rh immunoglobulin) is administered to Rh-negative mothers who have given birth to an Rh-positive infant. The purpose of RhoGAM is to prevent the mother’s immune system from becoming sensitized to Rh-positive blood cells. If an Rh-negative mother is exposed to Rh-positive fetal blood, her immune system may produce antibodies against the Rh antigen, which can cause hemolytic disease in future Rh-positive pregnancies. Administering RhoGAM within 72 hours after delivery prevents the formation of these antibodies.

Imagine the mother’s immune system as a guard that recognizes and attacks intruders (Rh-positive cells). RhoGAM acts like a disguise, preventing the guard from recognizing the intruders, thus avoiding an immune response.

Rh incompatibility can lead to hemolytic disease of the newborn (HDN) in subsequent pregnancies if the mother’s immune system becomes sensitized to Rh-positive blood. RhoGAM is also given during pregnancy at around 28 weeks and after any event where fetal blood might mix with maternal blood (e.g., miscarriage, amniocentesis). The timely administration of RhoGAM is crucial to ensure the health of both the current and future pregnancies.

 

✘ Incorrect answer options:

RH negative mothers with an RH negative infant: In this scenario, there is no risk of Rh incompatibility since both the mother and infant are Rh-negative, and RhoGAM is not needed.

RH positive mothers with an RH positive infant: Rh-positive mothers do not need RhoGAM because their immune system will not produce antibodies against Rh-positive cells.

RH positive mothers with an RH negative infant: Rh-positive mothers do not need RhoGAM regardless of the infant's Rh status because they will not form antibodies against Rh-positive cells.

 

References

• Cunningham, F. G., Leveno, K. J., Bloom, S. L., et al. (2018). *Williams Obstetrics, 25th Edition.* McGraw-Hill Education.
• American College of Obstetricians and Gynecologists. (2020). *Practice Bulletin No. 181: Prevention of Rh D Alloimmunization.* Obstetrics & Gynecology, 135(1), e57-e72.

EXPLANATION

 

✔ Correct answer:

Initiative versus guilt: According to Erik Erikson's stages of psychosocial development, a 5-year-old child is typically in the "Initiative versus Guilt" stage. This stage occurs approximately between the ages of 3 and 6 years. During this period, children begin to assert power and control over their environment by planning activities, engaging in play, and initiating activities with others. Successful navigation of this stage leads to a sense of initiative and the ability to lead others, while failure may result in feelings of guilt about desires and suppression of initiative.

Think of this stage as a child playing superhero. If they are encouraged to explore and try new things, they feel confident like a hero (initiative). If they are discouraged or overly criticized, they may feel guilty and unsure of themselves.

During the "Initiative versus Guilt" stage, children are learning to take initiative and make decisions. Encouraging their initiatives and providing supportive feedback helps foster a sense of purpose and leadership skills. Conversely, overly strict or critical responses can lead to feelings of guilt and inhibition of their natural tendencies to explore and take charge.

 

✘ Incorrect answer options:

Intimacy versus isolation: This stage occurs in young adulthood, typically between the ages of 18 and 40 years. It involves forming intimate, loving relationships with other people.

Autonomy versus shame and doubt: This stage occurs between the ages of 1 and 3 years. It focuses on developing a sense of personal control over physical skills and a sense of independence.

Trust versus mistrust: This stage occurs in infancy, from birth to approximately 18 months. It involves developing trust when caregivers provide reliability, care, and affection. A lack of this will lead to mistrust.

 

References

• Erikson, E. H. (1950). *Childhood and Society.* W.W. Norton & Company.
• Bee, H., & Boyd, D. (2013). *The Developing Child.* Pearson.

EXPLANATION

 

✔ Correct answer:

Celebrex: Celecoxib (Celebrex) is a nonsteroidal anti-inflammatory drug (NSAID) that is contraindicated during pregnancy, especially in the third trimester. It can cause premature closure of the ductus arteriosus in the fetus and can lead to oligohydramnios.

Coumadin: Warfarin (Coumadin) is an anticoagulant that is contraindicated during pregnancy due to its teratogenic effects. It can cause fetal warfarin syndrome, characterized by nasal hypoplasia, stippled epiphyses, and other skeletal abnormalities, as well as central nervous system malformations and bleeding complications.

Finasteride: Finasteride is used for benign prostatic hyperplasia and is contraindicated in women who are or may become pregnant. It can cause abnormalities in the external genitalia of a male fetus due to its antiandrogenic effects.

Think of these medications as foods that can harm a developing baby if consumed by a pregnant mother. Just as you would avoid certain foods to prevent harm, these medications are avoided to protect the fetus.

It is crucial for healthcare professionals to review and assess the safety of medications during pregnancy. Medications that pose risks to the fetus, whether due to teratogenic effects or other harmful mechanisms, should be identified and alternatives should be considered. Understanding the pharmacokinetics and teratogenic potential of each drug ensures the safety of both the mother and the developing fetus.

 

✘ Incorrect answer options:

Catapres: Clonidine (Catapres) is an antihypertensive medication that is generally considered safe during pregnancy, though it should be used under close medical supervision.

Habitrol: Nicotine replacement therapy (Habitrol) may be used during pregnancy if the benefits outweigh the risks. While nicotine can affect fetal development, the controlled use of nicotine patches may be safer than smoking.

Clofazimine: Clofazimine is used to treat leprosy and other conditions. While its safety during pregnancy is not well-studied, it is not specifically contraindicated. Its use should be evaluated on a case-by-case basis, weighing the benefits against potential risks.

 

References

• Briggs, G. G., Freeman, R. K., & Yaffe, S. J. (2017). *Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk.* Wolters Kluwer Health.
• Broussard, C. S., Louik, C., Honein, M. A., Mitchell, A. A., & National Birth Defects Prevention Study (2011). *Using Medications in Pregnancy: What Are the Issues?* Birth Defects Research Part A: Clinical and Molecular Teratology, 91(3), 241-245.

EXPLANATION

 

✔ Correct answer:

Red blood cells have a lifespan of 120 days: Red blood cells (RBCs) have an average lifespan of about 120 days in the human body. During this period, RBCs circulate through the bloodstream, delivering oxygen to tissues and removing carbon dioxide. After approximately 120 days, the old and damaged RBCs are typically removed from circulation by the spleen, and new RBCs are produced in the bone marrow to replace them.

Think of RBCs like the workers in a factory. They have a set period of work (120 days) before they retire (are removed by the spleen), and new workers (RBCs produced in the bone marrow) come in to replace them and keep the factory running smoothly.

Understanding the lifespan of RBCs is crucial for managing conditions related to blood health, such as anemia, and for understanding the impact of treatments like blood transfusions. Regular turnover of RBCs ensures that the body maintains efficient oxygen transport and waste removal, which is essential for overall health and proper physiological function.

 

✘ Incorrect answer options:

Red blood cells have a lifespan of 45 days: This is incorrect. RBCs live significantly longer than 45 days under normal physiological conditions.

Red blood cells have a lifespan of 60 days: This is incorrect. RBCs have a longer lifespan than 60 days, typically around twice that duration.

Red blood cells have a lifespan of 90 days: This is incorrect. While RBCs live for a considerable length of time, their average lifespan is longer than 90 days, closer to 120 days.

 

References

• McKenzie, S. B., & Williams, J. L. (2015). *Clinical Laboratory Hematology.* Pearson.
• Klein, H. G., & Anstee, D. J. (2014). *Mollison's Blood Transfusion in Clinical Medicine.* John Wiley & Sons.

EXPLANATION

 

✔Correct answer:

Multiple Sclerosis. Multiple Sclerosis (MS) is a chronic autoimmune disease that affects the central nervous system, leading to demyelination and neurodegeneration. The primary treatment for MS focuses on managing symptoms and modifying the disease course using immunomodulatory and immunosuppressive therapies. Erythromycin, an antibiotic, is not used in the treatment of MS because it does not have any effect on the immune-mediated processes or the symptoms associated with MS.

Think of erythromycin as a firefighter who specializes in putting out bacterial fires. Multiple Sclerosis, on the other hand, is like a faulty electrical system causing short circuits in a house. You wouldn't call a firefighter to fix the electrical system; you'd need an electrician. Similarly, erythromycin is not used for MS because it's designed to fight bacterial infections, not to manage autoimmune diseases.

In clinical practice, it's crucial to match the appropriate medication to the specific condition. Erythromycin is an antibiotic that is effective against a range of bacterial infections. It works by inhibiting protein synthesis in bacteria, making it useful for treating conditions caused by susceptible bacteria. Nurses must be knowledgeable about the indications and limitations of antibiotics to avoid inappropriate use and to ensure that patients receive the most effective treatment for their conditions.

 

✘Incorrect answer options:

Pneumonia. Erythromycin is commonly prescribed for bacterial pneumonia, particularly when caused by atypical bacteria like Mycoplasma pneumoniae. It is effective in treating respiratory tract infections.

Campylo Bacterial infection. Erythromycin is an effective treatment for Campylobacter infections, which typically cause gastrointestinal symptoms like diarrhea, abdominal pain, and fever. It helps reduce the severity and duration of symptoms.

Legionnaires disease. Erythromycin is one of the antibiotics used to treat Legionnaires' disease, a severe form of pneumonia caused by Legionella bacteria. It helps eliminate the infection and reduce symptoms.

 

References

• Lehne, R. A., Moore, L. K., Crosby, L., & Hamilton, D. (2019). Pharmacology for Nursing Care. Elsevier.
• Ignatavicius, D. D., & Workman, M. L. (2020). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.

EXPLANATION

 

✔Correct answers:

Feeling exhausted after a night’s sleep. One of the hallmark symptoms of insomnia is waking up feeling unrefreshed or exhausted despite having had a full night of sleep. This indicates poor sleep quality, which is a key aspect of insomnia.

Having trouble staying asleep throughout the night. Insomnia often involves difficulty maintaining sleep, leading to frequent awakenings or difficulty returning to sleep after waking up during the night.

Taking a long time to fall asleep initially. Difficulty initiating sleep, or taking a long time to fall asleep, is a common symptom of insomnia. This can be due to various factors, including stress, anxiety, or an irregular sleep schedule.

Think of insomnia as trying to charge a phone with a faulty charger. Even if you leave it plugged in all night (time in bed), the phone might still be low on battery (feeling exhausted) because the charge was intermittent or too slow (trouble staying asleep, taking a long time to fall asleep).

Identifying insomnia involves recognizing the various patterns of sleep disturbance that impact overall sleep quality and daytime functioning. Proper assessment of these symptoms helps in diagnosing and managing insomnia effectively. Interventions may include sleep hygiene education, cognitive-behavioral therapy for insomnia (CBT-I), and, in some cases, pharmacological treatments.

 

✘Incorrect answer option:

Falling asleep at inappropriate or unintended times. This symptom is more indicative of narcolepsy or other sleep disorders involving excessive daytime sleepiness rather than insomnia. Insomnia is characterized by difficulty initiating or maintaining sleep, not by falling asleep unexpectedly during the day.

 

References

• Lehne, R. A., Moore, L. K., Crosby, L., & Hamilton, D. (2019). Pharmacology for Nursing Care. Elsevier.
• Ignatavicius, D. D., & Workman, M. L. (2020). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.

EXPLANATION

 

✔ Correct answer:

Leafy green vegetables and liver: Leafy green vegetables (such as spinach, kale, and broccoli) and liver are among the richest sources of folic acid. Folic acid, also known as folate when found in food, is essential for DNA synthesis, cell division, and proper development during pregnancy. These foods provide high concentrations of folate, which is crucial for preventing neural tube defects in developing fetuses and for supporting overall health.

Think of folic acid as a key ingredient in a recipe for healthy cells. Leafy greens and liver are like superfoods packed with this key ingredient, making them excellent choices for boosting folic acid intake.

Folic acid is vital for various bodily functions, particularly in women of childbearing age. It helps in the formation of red blood cells and supports the proper closure of the neural tube during early fetal development. Consuming a diet rich in folic acid is crucial for maintaining adequate levels and preventing deficiencies.

 

✘ Incorrect answer options:

Yellow vegetables and various red meats: While these foods provide other essential nutrients, they are not particularly high in folic acid compared to leafy green vegetables and liver.

Carrots exclusively: Carrots are a good source of beta-carotene (vitamin A) but are not particularly high in folic acid.

Dairy products like milk: Dairy products are important for calcium and vitamin D intake but do not contain significant amounts of folic acid.

 

References

• National Institutes of Health. (2020). *Folate Fact Sheet for Health Professionals.* Retrieved from https://ods.od.nih.gov/factsheets/Folate-HealthProfessional/
• Gropper, S. S., Smith, J. L., & Carr, T. P. (2018). *Advanced Nutrition and Human Metabolism.* Cengage Learning.

EXPLANATION

 

✔ Correct answer:

Ensure a secure and safe environment for the patient: As the charge nurse, your primary responsibility is to ensure a secure and safe environment for the patient who is blind and deaf. This involves making sure that the patient's physical surroundings are free from hazards, such as ensuring clear pathways, proper lighting, and the use of tactile markers or devices to aid in navigation and orientation. Safety is paramount to prevent falls, injuries, and any other accidents that could occur due to the patient’s sensory deficits.

Think of creating a safe environment for the patient as childproofing a home. Just as you would remove dangerous objects and make the home safe for a child, you need to ensure that the patient's surroundings are free of hazards that could cause injury.

Ensuring a secure environment includes assessing the patient’s room for potential risks, providing assistive devices, and educating staff on the specific needs and safety protocols for caring for a patient with sensory impairments. It also involves communicating effectively with the patient using appropriate methods, such as tactile sign language or communication boards, to keep them informed and oriented.

 

✘ Incorrect answer options:

Discuss with your supervisor any safety concerns regarding the patient: While discussing safety concerns with your supervisor is important, it is not the primary responsibility. The primary focus should be on taking immediate and direct actions to ensure the patient’s safety.

Inform other staff members about the patient’s sensory deficits: Informing other staff members is necessary for coordinated care, but it is a secondary responsibility compared to ensuring a safe environment.

Keep the patient regularly informed about the social environment: While keeping the patient informed about the social environment can help with their comfort and orientation, it is not as critical as ensuring their physical safety and preventing injuries.

 

References

• Ackley, B. J., & Ladwig, G. B. (2013). *Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care.* Elsevier Health Sciences.
• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). *Fundamentals of Nursing.* Elsevier Health Sciences.

EXPLANATION

 

✔ Correct answer:

Weight gain: Weight gain is a common clinical sign in infants with congenital heart defects due to fluid retention. Infants with heart defects often have compromised cardiac function, which can lead to congestive heart failure. This can cause fluid to accumulate in the body, leading to edema and weight gain. Additionally, these infants may experience difficulty feeding and may tire easily, which can also contribute to changes in weight.

Think of the heart as a pump that helps keep water (fluid) moving through pipes (blood vessels). If the pump isn’t working well, water can start to back up and collect in certain areas, leading to weight gain from fluid retention.

Congenital heart defects can lead to heart failure, where the heart is unable to pump blood effectively. This results in poor perfusion and fluid buildup, often visible as weight gain. Monitoring weight, fluid balance, and signs of heart failure is critical in managing infants with congenital heart defects.

 

✘ Incorrect answer options:

Irregular white blood cell (WBC) lab values: Irregular WBC values are not typically associated with congenital heart defects. They are more indicative of infections or immune system disorders.

A slow pulse rate: A slow pulse rate (bradycardia) is not a common sign of congenital heart defects. In fact, these infants might exhibit tachycardia (fast heart rate) due to the heart working harder to compensate for the defect.

A decrease in systolic blood pressure: While blood pressure may be affected by congenital heart defects, a decrease in systolic blood pressure is not the most prominent or consistent sign. Blood pressure changes can vary depending on the specific type and severity of the heart defect.

 

References

• Park, M. K. (2014). *Park's Pediatric Cardiology for Practitioners.* Elsevier Health Sciences.
• Moss, A. J., Adams, F. H., & Emmanouilides, G. C. (2016). *Heart Disease in Infants, Children, and Adolescents: Including the Fetus and Young Adult.* Lippincott Williams & Wilkins.

EXPLANATION

 

✔Correct answers:

Conducting gastric lavage. Gastric lavage can be used to remove the contents of the stomach if the overdose is identified early, typically within 1-2 hours of ingestion. This procedure helps to reduce the amount of the drug absorbed into the system.

Administering Flumazenil. Flumazenil is a benzodiazepine antagonist that can rapidly reverse the sedative effects of benzodiazepines. It is administered intravenously and is particularly useful in cases of acute overdose to counteract respiratory depression and sedation.

Using activated charcoal and a saline cathartic. Activated charcoal is effective in adsorbing benzodiazepines in the gastrointestinal tract, reducing systemic absorption. A saline cathartic may be used to promote rapid elimination of the charcoal-drug complex from the gastrointestinal tract.

Think of a benzodiazepine overdose like accidentally ingesting a toxic substance. Using gastric lavage is like quickly rinsing out the mouth and stomach, activated charcoal is like using a sponge to soak up the toxin, and Flumazenil is like an antidote that neutralizes the poison's effect.

Managing a benzodiazepine overdose requires prompt and effective interventions to prevent severe complications such as respiratory depression and coma. Nurses must be familiar with both pharmacological and non-pharmacological treatment options, including the use of Flumazenil, gastric lavage, and activated charcoal. Timely and appropriate interventions can significantly improve patient outcomes in cases of benzodiazepine overdose.

 

✘Incorrect answer options:

Performing hemodialysis. Hemodialysis is not typically effective for benzodiazepine overdose because benzodiazepines are highly protein-bound and have a large volume of distribution, making them poorly dialyzable.

Administering syrup of ipecac. Syrup of ipecac is no longer recommended for inducing emesis in cases of poisoning or overdose due to the risk of aspiration and limited evidence of benefit.

 

References

• Lehne, R. A., Moore, L. K., Crosby, L., & Hamilton, D. (2019). Pharmacology for Nursing Care. Elsevier.
• Ignatavicius, D. D., & Workman, M. L. (2020). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.

EXPLANATION

 

✔ Correct answer:

Corgard: Corgard (nadolol) is a beta-blocker used to treat hypertension and angina. It should be stored at room temperature and not in the refrigerator. Storing it in the refrigerator could lead to degradation or reduced efficacy of the medication.

Think of medications like certain foods; some need refrigeration to stay fresh, while others do not. Corgard is like a loaf of bread—it stays best at room temperature and does not belong in the fridge.

Proper storage of medications is crucial to maintain their stability, efficacy, and safety. Medications have specific storage requirements based on their chemical composition. Refrigerating medications that should be kept at room temperature can lead to unwanted changes in their properties, while failure to refrigerate those that need it can reduce their potency or cause spoilage.

 

✘ Incorrect answer options:

Humulin (injection): Humulin (insulin) requires refrigeration to maintain its stability and potency. It should be stored in the refrigerator until the expiration date.

Epogen (injection): Epogen (epoetin alfa) is a medication used to treat anemia, especially in patients with chronic kidney disease. It must be refrigerated to preserve its stability and effectiveness.

Urokinase: Urokinase is a thrombolytic agent used to dissolve blood clots. It requires refrigeration to maintain its potency and should be stored in the refrigerator as recommended.

 

References

• Baxter, K. (2019). *Stockley's Drug Interactions: A Source Book of Interactions, Their Mechanisms, Clinical Importance and Management.* Pharmaceutical Press.
• Lexicomp. (2020). *Drug Information Handbook.* Wolters Kluwer.

EXPLANATION

 

✔ Correct answer:

Oily skin condition: An oily skin condition is not typically associated with Down’s syndrome. Individuals with Down’s syndrome often have dry, sensitive skin rather than oily skin. Common dermatological issues include xerosis (dry skin), seborrheic dermatitis, and an increased risk of infections due to compromised skin integrity.

Imagine Down’s syndrome as a puzzle with specific pieces that fit together to show a certain picture. Dry skin is one of those pieces, while oily skin is not a part of this particular puzzle.

Down’s syndrome is characterized by a variety of physical and developmental features. Generalized hypotonicity (decreased muscle tone), brachycephalic skull formation (broad, short skull), and the presence of a simian crease (a single palmar crease) are common features. Recognizing these characteristics helps healthcare providers deliver appropriate care and support.

 

✘ Incorrect answer options:

Generalized hypotonicity: Hypotonia, or decreased muscle tone, is a common characteristic in individuals with Down’s syndrome. It affects motor development and contributes to difficulties with physical activities.

Brachycephalic skull formation: Brachycephaly, a broad and short skull, is another common feature of Down’s syndrome, often leading to a flattened appearance of the head.

Presence of a simian crease: A simian crease, a single transverse palmar crease, is frequently observed in individuals with Down’s syndrome and is considered a notable physical characteristic.

 

References

• Bull, M. J. (2011). *Health supervision for children with Down syndrome.* Pediatrics, 128(2), 393-406.
• Roizen, N. J., & Patterson, D. (2003). *Down's syndrome.* The Lancet, 361(9365), 1281-1289.

EXPLANATION

 

✔ Correct answer:

13 year old female – 105 b.p.m., 22 resp/min, 105/60 mm Hg. The vital signs for a 13-year-old female listed as 105 beats per minute (b.p.m.) for heart rate, 22 respirations per minute (resp/min), and 105/60 mm Hg for blood pressure, include a heart rate that is higher than normal for her age group. The normal heart rate for a child aged 12-15 is typically 60-100 b.p.m. The other vital signs fall within the normal range for this age group, but the elevated heart rate indicates an abnormality.

Imagine a fan designed to operate at a specific speed for optimal performance and energy efficiency. If the fan is running faster than its intended speed, it indicates a potential problem, such as overheating or a malfunctioning motor. Similarly, a heart rate higher than the normal range in a 13-year-old girl suggests that something might be wrong, and it needs to be checked and addressed to ensure the body is functioning properly.

Elevated heart rates in adolescents can be caused by various factors, including anxiety, fever, dehydration, anemia, or underlying medical conditions. It is important to assess the child further to determine the cause of the elevated heart rate and address any underlying issues.

 

✘ Incorrect answer options:

5 year old male – 102 b.p.m, 24 resp/min, 90/65 mm Hg: These vital signs are within the normal range for a 5-year-old child. The normal heart rate for children aged 4-6 is 75-115 b.p.m., respiratory rate is 20-30 resp/min, and blood pressure is typically around 90-110/50-75 mm Hg.

11 year old male – 90 b.p.m, 22 resp/min, 100/70 mm Hg: These vital signs are within the normal range for an 11-year-old child. The normal heart rate for children aged 10-12 is 70-110 b.p.m., respiratory rate is 16-22 resp/min, and blood pressure is typically around 90-120/60-80 mm Hg.

6 year old female – 100 b.p.m., 26 resp/min, 90/70 mm Hg: These vital signs are within the normal range for a 6-year-old child. The normal heart rate for children aged 6-8 is 75-115 b.p.m., respiratory rate is 20-25 resp/min, and blood pressure is typically around 90-110/55-75 mm Hg.

 

References

• Hockenberry, M. J., & Wilson, D. (2018). *Wong's Essentials of Pediatric Nursing.* Elsevier.
• American Heart Association. (2020). *Normal Vital Signs by Age.* Retrieved from https://www.heart.org/

EXPLANATION

 

✔ Correct answer:

Immunoglobulin G (IgG): Immunoglobulin G (IgG) is the only type of antibody that can cross the placenta from the mother to the fetus. This transfer provides the developing baby with passive immunity, offering protection against infections during the early months of life until the baby's immune system becomes more developed. IgG antibodies are vital in protecting against a variety of bacterial and viral infections.

Think of IgG as a protective shield passed from the mother to the baby. Just like a mother bird provides a nest for her chicks to keep them safe, IgG antibodies cross the placenta to protect the baby from infections until its own immune system can take over.

The transfer of IgG antibodies occurs primarily during the third trimester of pregnancy. This passive immunity is crucial for the newborn, who has an immature immune system and is more vulnerable to infections. Other immunoglobulins, such as IgA, IgD, and IgE, do not cross the placenta. Instead, they play different roles in the immune response and are present in different body fluids and tissues.

 

✘ Incorrect answer options:

Immunoglobulin A (IgA): IgA is primarily found in mucosal areas, such as the gut, respiratory tract, and urogenital tract, as well as in secretions like saliva, tears, and breast milk. It does not cross the placenta.

Immunoglobulin D (IgD): IgD is present in small amounts in the blood and primarily serves as a receptor on B cells. It does not cross the placenta.

Immunoglobulin E (IgE): IgE is associated with allergic reactions and defense against parasitic infections. It does not cross the placenta and is found mainly in the lungs, skin, and mucous membranes.

 

References

• Goldsby, R. A., Kindt, T. J., & Osborne, B. A. (2003). *Kuby Immunology.* W.H. Freeman and Company.
• Abbas, A. K., Lichtman, A. H., & Pillai, S. (2017). *Cellular and Molecular Immunology.* Elsevier.

EXPLANATION

 

✔Correct answer:

Borrelia burgdorferi. Lyme disease is caused by the bacterium Borrelia burgdorferi, which is transmitted to humans through the bite of infected black-legged ticks, commonly known as deer ticks. This spirochete bacterium is responsible for the characteristic symptoms of Lyme disease, which include erythema migrans (a bullseye-shaped rash), fever, headache, fatigue, and, if left untreated, can lead to more severe symptoms affecting the joints, heart, and nervous system. Early diagnosis and treatment with antibiotics are crucial to prevent complications.

Think of Borrelia burgdorferi like a tiny saboteur hiding in the woods, waiting to hitch a ride on a tick. When the tick bites, the saboteur sneaks into the body and causes trouble, much like how this bacterium enters the bloodstream and causes the symptoms of Lyme disease.

Educating patients about the causative agent of Lyme disease helps them understand the importance of preventive measures, such as avoiding tick-infested areas, using insect repellent, and performing regular tick checks. Nurses play a vital role in raising awareness about the early signs of Lyme disease and the need for prompt medical attention if a tick bite is suspected. This education can significantly reduce the risk of long-term complications associated with untreated Lyme disease.

 

✘Incorrect answer options:

Enterococcus faecalis. Enterococcus faecalis is a bacterium commonly associated with urinary tract infections, bacteremia, and endocarditis but is not related to Lyme disease.

Bacillus anthracis. Bacillus anthracis is the bacterium that causes anthrax, a serious infectious disease, and is unrelated to Lyme disease.

Streptococcus pyogenes. Streptococcus pyogenes is responsible for diseases such as strep throat, scarlet fever, and necrotizing fasciitis but is not the causative agent of Lyme disease.

 

References

• Lehne, R. A., Moore, L. K., Crosby, L., & Hamilton, D. (2019). Pharmacology for Nursing Care. Elsevier.
• Ignatavicius, D. D., & Workman, M. L. (2020). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.

EXPLANATION

 

✔ Correct answer:

Nitro Dur: Nitro Dur (nitroglycerin) is not associated with photosensitivity reactions. It is primarily used as a vasodilator for the management of angina pectoris and does not cause photosensitive reactions in patients. Therefore, it can be considered safe regarding photosensitivity.

Think of photosensitivity as a sunburn you get from certain medications. Just as you avoid certain activities to prevent a sunburn, some medications need to be avoided to prevent a photosensitive reaction. Nitro Dur is like a hat that protects you from the sun—it doesn’t contribute to sunburn (photosensitivity).

Understanding which medications are associated with photosensitivity is crucial for patient safety. Photosensitive reactions can range from mild sunburn-like effects to severe blistering and skin damage upon exposure to sunlight. Identifying medications that do not cause such reactions helps in managing patient care effectively, especially for those with a history of photosensitivity.

 

✘ Incorrect answer options:

Noroxin: Norfloxacin (Noroxin) is a fluoroquinolone antibiotic known to cause photosensitivity reactions.

Accutane: Isotretinoin (Accutane) is a retinoid that is highly associated with photosensitivity reactions. Patients are advised to avoid excessive sunlight and UV exposure while on this medication.

Sulfonamide: Sulfonamides are a class of antibiotics known to cause photosensitivity reactions. Patients taking these medications are often advised to use sun protection.

Bactrim: Trimethoprim-sulfamethoxazole (Bactrim) is another sulfonamide antibiotic associated with photosensitivity. Patients should be cautious about sun exposure while taking this medication.

Cipro: Ciprofloxacin (Cipro) is a fluoroquinolone antibiotic that can cause photosensitivity reactions. Like other fluoroquinolones, it increases the skin's sensitivity to sunlight.

 

References

• Aronson, J. K. (2016). *Meyler's Side Effects of Drugs: The International Encyclopedia of Adverse Drug Reactions and Interactions.* Elsevier.
• McEvoy, G. K. (2019). *AHFS Drug Information.* American Society of Health-System Pharmacists.

EXPLANATION

 

✔Correct answer:

Haemophilus aegyptius. Haemophilus aegyptius, also known as Koch-Weeks bacillus, is a well-known bacterium responsible for causing conjunctivitis, commonly referred to as "pink eye." This microorganism is highly contagious and typically spreads through direct contact with infected secretions or contaminated surfaces. Conjunctivitis caused by Haemophilus aegyptius often presents with symptoms such as redness, swelling, itching, and discharge from the eyes. Proper hygiene and appropriate antibiotic treatment are essential for managing and preventing the spread of this infection.

Imagine Haemophilus aegyptius as a little prankster that sneaks into a classroom and sprinkles itching powder on everyone's desks. Just as the powder causes everyone to itch, sneeze, and feel uncomfortable, this bacterium causes the eyes to become red, itchy, and produce discharge, leading to the uncomfortable symptoms of conjunctivitis.

Recognizing the causative agents of common infections like conjunctivitis is crucial for effective patient care. Haemophilus aegyptius is just one of several pathogens that can cause this condition. Understanding the specific microorganism involved helps in selecting the appropriate antibiotic therapy and implementing infection control measures. Nurses play a key role in educating patients and their families about the importance of hand hygiene and avoiding the sharing of personal items to prevent the spread of conjunctivitis.

 

✘Incorrect answer options:

Vibrio cholera. Vibrio cholera is the bacterium responsible for causing cholera, an acute diarrheal illness, not conjunctivitis.

Helicobacter pylori. Helicobacter pylori is associated with peptic ulcer disease and chronic gastritis, not conjunctivitis.

Yersinia pestis. Yersinia pestis is the bacterium responsible for causing plague, not conjunctivitis.

 

References

• Lehne, R. A., Moore, L. K., Crosby, L., & Hamilton, D. (2019). Pharmacology for Nursing Care. Elsevier.
• Ignatavicius, D. D., & Workman, M. L. (2020). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.

EXPLANATION

 

✔Correct answer:

Elavil: Elavil, also known by its generic name Amitriptyline, is a tricyclic antidepressant (TCA). It is primarily used to treat symptoms of depression and anxiety. Amitriptyline works by increasing the levels of certain neurotransmitters (serotonin and norepinephrine) in the brain, which helps improve mood and emotional balance. It's particularly effective for patients who experience both depression and anxiety, and it can also be prescribed for chronic pain conditions and migraine prophylaxis.

Think of Elavil like a mood balancer. Just as you might adjust the settings on a thermostat to achieve a comfortable room temperature, Elavil helps adjust the levels of neurotransmitters in the brain to maintain a balanced mood and reduce symptoms of depression and anxiety.

When assessing a patient who reports taking medication for depression and anxiety, it's important to consider common antidepressants like Elavil. Understanding the pharmacodynamics and potential side effects of TCAs, such as dry mouth, drowsiness, and orthostatic hypotension, is crucial for providing comprehensive care. Monitoring for therapeutic effectiveness and any adverse reactions is essential, especially since TCAs can interact with other medications the patient might be taking.

 

✘Incorrect answer options:

Pergolide. Pergolide is a dopamine agonist used primarily in the treatment of Parkinson's disease. It helps improve motor function but is not indicated for the treatment of depression or anxiety.

Calcitonin. Calcitonin is a hormone used to treat conditions such as osteoporosis and hypercalcemia. It plays a role in calcium regulation and bone metabolism but has no effect on mood disorders.

Verapamil. Verapamil is a calcium channel blocker used to treat hypertension, angina, and certain arrhythmias. It can also be used for migraine prevention but is not used to manage depression or anxiety.

 

References

• Lehne, R. A., Moore, L. K., Crosby, L., & Hamilton, D. (2019). Pharmacology for Nursing Care. Elsevier.
• Varcarolis, E. M., & Halter, M. J. (2018). Foundations of Psychiatric Mental Health Nursing: A Clinical Approach. Elsevier.

EXPLANATION

 

✔Correct answer:

Sudden weight gain. In an acute episode of diabetic ketoacidosis (DKA), patients typically experience symptoms resulting from high blood sugar levels and ketone buildup in the body. Common symptoms include a noticeable acetone breath smell (often described as fruity or like nail polish remover), intense thirst (polydipsia), and episodes of vomiting due to metabolic disturbances. Sudden weight gain is not expected during an acute episode of ketoacidosis; in fact, weight loss is more common due to dehydration and the body breaking down fat and muscle for energy.

Think of diabetic ketoacidosis like a car running out of fuel and starting to burn oil and other fluids, causing the engine to emit unusual smells and overheat (acetone breath and intense thirst). Instead of gaining weight, the car (patient) loses fluids and breaks down internal components (vomiting and weight loss) to keep going.

Diabetic ketoacidosis is a serious complication of diabetes that requires prompt medical attention. Recognizing the hallmark symptoms such as acetone breath, polydipsia, polyuria, abdominal pain, and vomiting is critical for early intervention. Nurses must also monitor for dehydration and electrolyte imbalances that can accompany DKA. Management typically involves fluid replacement, insulin therapy, and correcting metabolic imbalances to stabilize the patient.

 

✘Incorrect answer options:

Noticeable acetone breath smell. Acetone breath is a classic sign of ketoacidosis due to the breakdown of ketones.

Intense thirst. Intense thirst, or polydipsia, is common in ketoacidosis as the body attempts to counteract dehydration caused by high blood sugar levels.

Episodes of vomiting. Vomiting occurs frequently in DKA due to metabolic acidosis and gastrointestinal irritation from elevated ketone levels.

 

References

• Lehne, R. A., Moore, L. K., Crosby, L., & Hamilton, D. (2019). Pharmacology for Nursing Care. Elsevier.
• Ignatavicius, D. D., & Workman, M. L. (2020). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.

EXPLANATION

 

✔ Correct answer:

Streptokinase for clot dissolution: Streptokinase is a thrombolytic agent used to dissolve blood clots that are obstructing the coronary arteries during an acute myocardial infarction (MI). Administering streptokinase within the first few hours after the onset of an MI can help restore blood flow to the heart muscle, reduce the size of the infarct, and improve patient outcomes by minimizing myocardial damage.

Think of the blocked coronary artery as a clogged pipe. Streptokinase works like a powerful drain cleaner that dissolves the clot, allowing blood to flow freely again and preventing further damage to the heart muscle.

Early intervention with thrombolytic therapy is critical in the management of acute MI. Time is a crucial factor; the sooner thrombolytic therapy is initiated, the better the chances of limiting myocardial damage and improving survival rates. Streptokinase, along with other thrombolytic agents like tissue plasminogen activator (tPA), plays a vital role in the acute management of MI.

 

✘ Incorrect answer options:

Acetaminophen for pain management: Acetaminophen is not effective for managing the chest pain associated with an MI. Instead, opioids like morphine are commonly used for pain relief in this scenario.

Atropine for cardiac function support: Atropine is used to treat bradycardia and certain types of heart block, but it is not a primary treatment for acute MI.

Coumadin for long-term anticoagulation: Coumadin (warfarin) is an oral anticoagulant used for long-term prevention of thromboembolic events. It is not used in the immediate treatment phase of an acute MI, where rapid action is required to dissolve the clot.

 

References

• Antman, E. M., Anbe, D. T., Armstrong, P. W., et al. (2004). *ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction—executive summary.* Circulation, 110(5), 588-636.
• Kushner, F. G., Hand, M., Smith, S. C., et al. (2009). *2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update).* Journal of the American College of Cardiology, 54(23), 2205-2241.

EXPLANATION

 

✔ Correct answer:

Begin prophylactic treatment with AZT (Zidovudine): The most crucial step following a needlestick injury involving a patient diagnosed with AIDS is to begin post-exposure prophylaxis (PEP) with antiretroviral medications as soon as possible. AZT (Zidovudine) is a commonly used medication in PEP regimens to reduce the risk of HIV transmission. Starting PEP within hours of exposure is essential for its effectiveness, and the treatment typically continues for 28 days.

Imagine getting a small burn on your hand. You immediately apply a burn ointment to prevent infection and promote healing. Similarly, initiating PEP with AZT right after a needlestick injury acts like the burn ointment, helping to prevent HIV infection from taking hold.

Immediate actions following a needlestick injury include washing the area with soap and water, reporting the incident to the appropriate authorities, and starting PEP as quickly as possible. PEP involves a combination of antiretroviral medications, with AZT being a key component, to prevent seroconversion. Follow-up testing and monitoring are necessary to ensure the effectiveness of the prophylaxis and to address any side effects from the medication.

 

✘ Incorrect answer options:

Consult a counselor for support: While emotional support is important, it is not the immediate priority following a needlestick injury. The primary focus should be on preventing HIV transmission.

Initiate prophylactic treatment with Pentamidine: Pentamidine is not used for post-exposure prophylaxis of HIV. It is used to treat or prevent Pneumocystis pneumonia (PCP), a specific opportunistic infection, in immunocompromised patients.

Consult with a social worker promptly: Although consulting with a social worker might be beneficial for addressing the psychological and social aspects of the incident, it is not the immediate priority. The first step should be to begin PEP to reduce the risk of HIV transmission.

 

References

• Centers for Disease Control and Prevention (CDC). (2016). *Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis.*
• Kuhar, D. T., Henderson, D. K., Struble, K. A., et al. (2013). *Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis.* Infection Control & Hospital Epidemiology, 34(9), 875-892.

EXPLANATION

 

✔Correct answer:

Frequent migraines. Hyperkalemia, an elevated level of potassium in the blood, primarily affects the muscular and cardiovascular systems. Symptoms of acute hyperkalemia typically include muscle weakness, paralysis, paresthesias (tingling sensations), and cardiac symptoms such as arrhythmias or bradycardia (reduced heart rate). Migraines, however, are not typically associated with hyperkalemia. Migraines are a neurological condition often related to factors such as stress, hormonal changes, and dietary triggers, rather than electrolyte imbalances like hyperkalemia.

Think of hyperkalemia as a problem with the electrical wiring in a house that primarily affects the lights and appliances (representing muscles and the heart). If the wiring is faulty, you'd expect the lights to flicker or appliances to malfunction (muscle weakness and heart issues), but it wouldn't cause a problem with the plumbing (representing migraines), which is a different system altogether.

Recognizing the symptoms associated with electrolyte imbalances like hyperkalemia is crucial for prompt and effective treatment. Hyperkalemia can lead to life-threatening conditions if not addressed quickly. Symptoms such as muscle weakness, paresthesias, and cardiac dysrhythmias are direct consequences of elevated potassium levels affecting muscle and nerve function. Understanding these manifestations helps nurses to differentiate between related and unrelated symptoms, ensuring accurate diagnosis and appropriate interventions.

 

✘Incorrect answer options:

Mild paresthesias. Mild paresthesias, or tingling sensations, are common in hyperkalemia due to the effect of elevated potassium on nerve function.

Noticeable muscle weakness in the extremities. Muscle weakness is a typical symptom of hyperkalemia, resulting from its impact on neuromuscular transmission.

Reduced heart rate. A reduced heart rate (bradycardia) can occur in hyperkalemia as it affects the cardiac conduction system, potentially leading to severe arrhythmias.

 

References

• Lehne, R. A., Moore, L. K., Crosby, L., & Hamilton, D. (2019). Pharmacology for Nursing Care. Elsevier.
• Ignatavicius, D. D., & Workman, M. L. (2020). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.

EXPLANATION

 

✔ Correct answer:

Intimacy versus isolation: According to Erik Erikson's stages of psychosocial development, a 20-year-old young adult is typically in the "Intimacy versus Isolation" stage. This stage occurs during young adulthood, approximately between the ages of 18 and 40 years. During this period, individuals focus on forming intimate, loving relationships with other people. Successful navigation of this stage results in strong relationships and a sense of connectedness, while failure can lead to loneliness and isolation.

Think of this stage as building bridges. If the young adult is able to build strong, supportive bridges (relationships) with others, they feel connected and secure (intimacy). If they are unable to build these bridges, they may feel isolated and alone.

The "Intimacy versus Isolation" stage is crucial for developing meaningful relationships and emotional connections. Successful resolution of this stage allows individuals to form deep, lasting bonds with others, which are essential for emotional well-being and social stability. Support from family, friends, and romantic partners plays a significant role in navigating this stage effectively.

 

✘ Incorrect answer options:

Trust versus mistrust: This stage occurs in infancy, from birth to approximately 18 months. It involves developing trust when caregivers provide reliability, care, and affection.

Initiative versus guilt: This stage occurs in early childhood, between the ages of 3 and 6 years. It involves developing a sense of initiative and the ability to plan and undertake activities.

Autonomy versus shame and doubt: This stage occurs in toddlerhood, between the ages of 1 and 3 years. It focuses on developing a sense of personal control over physical skills and a sense of independence.

 

References

• Erikson, E. H. (1950). *Childhood and Society.* W.W. Norton & Company.
• Bee, H., & Boyd, D. (2013). *The Developing Child.* Pearson.

EXPLANATION

 

✔ Correct answer:

Possible autonomic neuropathy: Autonomic neuropathy is a common complication of diabetes, particularly in patients with a long history of the disease. It affects the autonomic nervous system, which controls involuntary bodily functions, including bladder function. This condition can lead to bladder dysfunction, causing difficulty in urination or urinary retention. Given the patient's history of insulin-dependent diabetes, autonomic neuropathy is the most likely cause of his inability to urinate.

Think of the autonomic nervous system as the automatic settings on a car that control things like cruise control and automatic braking. When these systems malfunction, it becomes hard to control the car properly. Similarly, when autonomic neuropathy affects the bladder, it becomes difficult to control urination.

Diabetic autonomic neuropathy can affect various organs and systems, including the cardiovascular, gastrointestinal, and genitourinary systems. In the case of bladder dysfunction, the nerves that control the bladder muscles and sphincters are damaged, leading to problems such as urinary retention, incontinence, and incomplete bladder emptying. Regular monitoring and management of diabetes are essential to prevent or delay the onset of such complications.

 

✘ Incorrect answer options:

Potential atherosclerosis: While atherosclerosis is a common complication of diabetes and can lead to various vascular issues, it is not typically associated with urinary retention or difficulty in urination.

Likely somatic neuropathy: Somatic neuropathy affects the sensory and motor nerves, leading to symptoms such as pain, tingling, and weakness, but it does not directly cause urinary retention. It primarily affects the peripheral nervous system rather than the autonomic system.

Suspected diabetic nephropathy: Diabetic nephropathy refers to kidney damage caused by diabetes, which can lead to proteinuria, hypertension, and renal failure. While it affects kidney function, it is not directly associated with urinary retention or bladder dysfunction.

 

References

• Tesfaye, S., & Selvarajah, D. (2012). *Advances in the epidemiology, pathogenesis, and management of diabetic peripheral neuropathy.* Diabetes/Metabolism Research and Reviews, 28(S1), 8-14.
• American Diabetes Association. (2019). *Standards of Medical Care in Diabetes—2019.* Diabetes Care, 42(Supplement 1), S1-S193.