NCLEX- RN Practice Exam 4

EXPLANATION

 

✔ Correct answer:

Performing a blood sugar check. The symptoms of confusion, sweating, and pallor in a 29-year-old male suggest hypoglycemia, which is a condition where blood sugar levels drop below normal. Hypoglycemia can cause acute symptoms such as altered mental status, sweating, and pallor, and it requires immediate assessment and intervention. Performing a blood sugar check is a quick, non-invasive test that can rapidly determine if low blood glucose is the cause of the patient's symptoms. Immediate correction of hypoglycemia is crucial to prevent further complications such as seizures or loss of consciousness.

Think of the body as a car running low on fuel. If the fuel (blood sugar) gets too low, the car (body) starts to malfunction. Checking the fuel gauge (blood sugar level) first can quickly identify the problem and allow for immediate refueling (treatment).

Hypoglycemia is a common and potentially life-threatening condition, particularly in patients with diabetes or those taking insulin or other glucose-lowering medications. Rapid identification and treatment are essential. If hypoglycemia is confirmed, administering glucose can quickly alleviate symptoms. Further evaluation to determine the underlying cause of the hypoglycemia can be done after the patient is stabilized.

 

✘ Incorrect answer options:

Obtaining blood cultures. Blood cultures are used to diagnose infections, particularly bacteremia or sepsis. While important in certain contexts, they do not provide immediate information relevant to the acute symptoms of confusion, sweating, and pallor.

Conducting a CT scan. A CT scan might be considered if there is suspicion of a neurological event such as a stroke or head injury. However, it is not the first-line test for the symptoms described and is less immediate in providing critical information for the acute presentation.

Assessing arterial blood gases. Arterial blood gas (ABG) analysis can provide information about the patient's oxygenation, ventilation, and acid-base status. While useful in many scenarios, it is not the most immediate or straightforward test to determine the cause of the acute symptoms described.

 

References

• American Diabetes Association. (2020). Standards of Medical Care in Diabetes.
• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Winkelman, C. (2021). *Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care.* Elsevier.

EXPLANATION

 

✔ Correct answer:

A family history of heart disease.  A family history of heart disease is a significant hereditary risk factor for atherosclerosis. This means that if close relatives, such as parents or siblings, have had heart disease, there is a higher likelihood of developing atherosclerosis due to shared genetic factors. These genetic factors can include predispositions to high blood pressure, high cholesterol levels, and other conditions that contribute to the development of atherosclerosis.

Think of it like inheriting a blueprint for building a house. If heart disease runs in the family, you might inherit a blueprint that makes your "house" (body) more likely to develop problems with its "plumbing" (arteries).

Understanding hereditary risk factors is crucial in the prevention and management of atherosclerosis. While genetic predisposition cannot be changed, individuals can take proactive steps to mitigate other modifiable risk factors such as diet, exercise, and smoking cessation. Educating patients about their family history and encouraging regular screening and healthy lifestyle choices can significantly reduce the overall risk of cardiovascular diseases.

 

✘ Incorrect answer options:

Being overweight. While being overweight is a risk factor for atherosclerosis, it is not a hereditary factor. It is a modifiable lifestyle factor that can be managed through diet and exercise.

Smoking habits. Smoking is a major risk factor for atherosclerosis, but it is not inherited. It is a behavioral choice that can be modified to reduce the risk of heart disease.

Age. Age is a risk factor for atherosclerosis, but it is not hereditary. As individuals age, the risk of developing atherosclerosis increases due to the natural aging process and the cumulative effects of other risk factors.

 

References

• American Heart Association. (2020). Understanding Genetics and Heart Disease. Retrieved from www.heart.org.
• Libby, P., Ridker, P. M., & Hansson, G. K. (2011). Inflammation in Atherosclerosis: From Pathophysiology to Practice. *Journal of the American College of Cardiology*, 54(23), 2129-2138.

EXPLANATION

 

✔Correct answer:

Brain tumors in children can present with various signs and symptoms due to increased intracranial pressure and the specific location of the tumor affecting different neurological functions.

Head tilt: A child may develop a head tilt due to the tumor causing cranial nerve involvement, leading to muscle weakness or imbalance. This is a compensatory mechanism to maintain balance or reduce discomfort.

Vomiting: Vomiting, particularly in the morning, is a common sign of increased intracranial pressure. The tumor can cause obstruction of cerebrospinal fluid flow or direct pressure on the vomiting center in the brain.

Lethargy: Increased intracranial pressure and the metabolic demands of the tumor can lead to decreased energy levels and lethargy. This is often one of the early signs that parents might notice.

Imagine a balloon inside a box. As the balloon (tumor) grows, it presses against the sides of the box (brain), leading to discomfort and malfunction of the box's components (brain functions), causing symptoms like vomiting and lethargy.

When assessing a child with a brain tumor, it is critical to perform a comprehensive neurological examination, including assessments of cranial nerve function, motor skills, and cognitive abilities. Monitoring for signs of increased intracranial pressure and providing interventions to alleviate these symptoms are essential aspects of care. Collaboration with a multidisciplinary team, including neurology, oncology, and pediatric specialists, ensures holistic management of the child's condition.

 

✘Incorrect answer options:

Polydipsia: Polydipsia (excessive thirst) is more commonly associated with endocrine disorders such as diabetes mellitus or diabetes insipidus, rather than a direct symptom of a brain tumor.

Increased appetite: Increased appetite is not typically associated with brain tumors. In fact, children with brain tumors might experience a loss of appetite due to nausea, vomiting, or overall illness.

Increased pulse: An increased pulse rate is not a common primary symptom of brain tumors. Changes in vital signs might occur due to other factors such as pain, fever, or stress, but it is not specific to brain tumors.

References

• Hockenberry, M. J., & Wilson, D. (2018). Wong's Nursing Care of Infants and Children. 11th ed. Elsevier.
• McKinney, E. S., James, S. R., Murray, S. S., Nelson, K. A., & Ashwill, J. W. (2017). Maternal-Child Nursing. 5th ed. Elsevier.

EXPLANATION

 

✔ Correct answers:

Impulsiveness. Individuals with borderline personality disorder (BPD) often exhibit impulsive behaviors. This can include impulsive spending, unsafe sex, substance abuse, reckless driving, and binge eating. Impulsivity is a core characteristic of BPD and can lead to various harmful behaviors.

Lability of mood. Mood lability, or rapid and intense changes in mood, is common in BPD. Clients may experience extreme mood swings within a short period, often triggered by interpersonal stressors. This emotional instability is a hallmark of the disorder.

Self-destructive behavior. Self-destructive behaviors, such as self-harm, suicidal gestures, or attempts, are prevalent in individuals with BPD. These behaviors often arise from intense emotional pain, fear of abandonment, or attempts to regulate overwhelming emotions.

Think of BPD like a stormy sea. Impulsiveness and mood swings are like sudden, unpredictable waves, while self-destructive behaviors are the dangerous undertows that can pull someone down.

Understanding the typical characteristics of BPD helps in developing an effective care plan. Recognizing impulsiveness, mood lability, and self-destructive behavior as core aspects of BPD allows healthcare providers to implement targeted interventions and supportive strategies to manage these symptoms. Therapeutic approaches, including dialectical behavior therapy (DBT), are often employed to help clients develop healthier coping mechanisms and improve emotional regulation.

 

✘ Incorrect answer options:

Ritualistic behavior. Ritualistic behavior is more characteristic of obsessive-compulsive disorder (OCD) rather than BPD. Individuals with OCD engage in repetitive behaviors or mental acts to reduce anxiety, which is not typically a feature of BPD.

Psychomotor retardation. Psychomotor retardation, characterized by slowed physical movements and speech, is more commonly associated with severe depression rather than BPD. While individuals with BPD may experience depressive episodes, psychomotor retardation is not a primary symptom.

 

References

• American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).
• Linehan, M. M. (2018). Cognitive-Behavioral Treatment of Borderline Personality Disorder. Guilford Publications.

EXPLANATION

 

✔ Correct answers:

Verify the patency of the line by checking for blood return at regular intervals. Regularly checking for blood return ensures that the central venous line is patent and functioning correctly. This is crucial for the safe administration of chemotherapy, as it confirms that the line is correctly positioned in the vein.

Inspect the insertion site for any signs of swelling, erythema, or drainage. Inspecting the insertion site is essential for early detection of infection or other complications. Signs of swelling, erythema, or drainage can indicate infection or other issues that need to be addressed promptly to prevent further complications.

If unable to aspirate blood, reposition the client and ask them to cough to possibly clear or reposition the line. Repositioning the client and asking them to cough can help move the catheter tip if it is against the vessel wall or blocked by a small clot. These actions can help restore patency without the need for more invasive interventions.

Contact the healthcare provider to verify line placement if its status is uncertain or problematic. If there is any doubt about the line's placement or patency, contacting the healthcare provider is essential. This ensures that any issues are addressed promptly and prevents potential complications from administering chemotherapy through a compromised line.

Think of a central venous line like a garden hose. You need to check for water flow (blood return), ensure there are no kinks or leaks (inspect for swelling or drainage), and adjust the position if the flow is blocked (reposition client). If you still have issues, call the plumber (healthcare provider) to fix it.

Managing a central venous line requires vigilance to prevent complications such as infection, thrombosis, or catheter displacement. Regularly verifying patency, inspecting the site, and troubleshooting issues ensures safe and effective chemotherapy administration. Early intervention and communication with healthcare providers are critical components of comprehensive line management.

 

✘ Incorrect answer option:

Proceed with administering a cytotoxic agent even if a blood return is not evident. Administering a cytotoxic agent without confirming blood return is unsafe, as it may indicate that the line is not patent or properly positioned. This can lead to extravasation, causing severe tissue damage and other complications.

 

References

• Gorski, L. A., Hadaway, L., Hagle, M. E., Broadhurst, D., Clare, S., Kleidon, T., ... & Alexander, M. (2021). Infusion therapy standards of practice. Journal of Infusion Nursing, 44(1S), S1-S224.
• Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2019). Clinical Nursing Skills and Techniques. 9th ed. Elsevier.

EXPLANATION

 

✔Correct answer:

“I can usually keep my ostomy pouch on for 3 to 7 days before changing it.” This statement is correct because, with proper care, an ostomy pouch can typically be worn for 3 to 7 days before needing to be changed. This helps prevent skin irritation and ensures the adhesive remains effective.

“I must use a skin barrier to protect my skin from urine.” Using a skin barrier is essential to protect the peristomal skin from urine, which can cause skin irritation and breakdown if it comes into prolonged contact with the skin.

Think of the ostomy pouch like a bandage that needs to be changed every few days to keep the skin healthy (3 to 7 days), and the skin barrier as a protective lotion that prevents irritation from urine.

Educating clients on the importance of proper pouch change intervals and the use of skin barriers is crucial to prevent complications such as skin irritation and infection. Encouraging clients to follow a regular schedule for changing the pouch and checking for any signs of skin problems is part of comprehensive ostomy care.

 

✘Incorrect answer options:

“If I limit my fluid intake I will not have to empty my ostomy pouch as often.” Limiting fluid intake is not recommended as it can lead to dehydration and concentrated urine, which can irritate the stoma and surrounding skin. Adequate hydration is important for overall health and proper stoma function.

“I can place an aspirin tablet in my pouch to decrease odor.” Placing an aspirin tablet in the ostomy pouch is not recommended as it can damage the pouch material and does not effectively control odor. There are specialized products available for ostomy odor management.

“I should empty my ostomy pouch of urine when it is full.” It is important to empty the ostomy pouch when it is about one-third to half full to prevent leakage and undue pressure on the adhesive seal, which can cause the pouch to detach and lead to skin irritation or infection.

References

• Wound, Ostomy and Continence Nurses Society. (2016). WOCN Society Clinical Practice Ostomy Guidelines. Springer Publishing Company.
• Colwell, J. C., Goldberg, M. T., & Carmel, J. E. (2012). Fecal & Urinary Diversions: Management Principles. Mosby.

EXPLANATION

 

✔Correct answer:

The student experiences pain in the lower part of the knee. Osgood-Schlatter disease is a common cause of knee pain in adolescents, particularly those who are active in sports. It is an inflammation of the area just below the knee where the patellar tendon attaches to the tibia (shinbone). The condition is often associated with repetitive stress or overuse, which can occur during activities that involve running, jumping, and other high-impact movements. Adolescents, particularly during growth spurts, are more susceptible due to the rapid changes in their bones, muscles, and tendons.

Imagine a young tree growing quickly and being repeatedly bent in the wind. The area where the trunk meets the ground might become sore and inflamed due to the constant bending, similar to how the patellar tendon attachment site gets inflamed in Osgood-Schlatter disease.

The patellar tendon connects the kneecap (patella) to the shinbone (tibia). During periods of rapid growth, the bone, tendon, and muscle may grow at different rates, leading to tension and stress at the attachment site. Repetitive activities that involve running and jumping place additional stress on this area, causing inflammation and pain. The condition is typically self-limiting and resolves with rest, ice, and activity modification.

 

✘Incorrect answer options:

The condition results from the student’s intense schedule in competitive swimming. Osgood-Schlatter disease is more commonly associated with sports that involve running, jumping, and quick direction changes, such as soccer, basketball, and gymnastics. While swimming is a rigorous sport, it does not typically involve the type of high-impact activities that lead to Osgood-Schlatter disease.

Surgery is likely necessary for the student’s recovery. Surgery is rarely required for Osgood-Schlatter disease. Most cases are managed with conservative treatments such as rest, ice, anti-inflammatory medications, and physical therapy. The condition usually resolves on its own once the adolescent's growth spurt ends.

The student is using the condition as an excuse to avoid physical education. Osgood-Schlatter disease is a genuine medical condition that causes real pain and discomfort. It is not appropriate to dismiss it as an excuse. Proper management and understanding are essential to support the student’s health and recovery.

 

References

• Hinkle, J. L., & Cheever, K. H. (2017). *Brunner & Suddarth's Textbook of Medical-Surgical Nursing*. Wolters Kluwer.
• Canale, S. T., & Beaty, J. H. (2012). *Campbell's Operative Orthopaedics*. Elsevier.

EXPLANATION

 

✔ Correct answer:

Drawing a blood culture. Before starting antibiotic treatment, it is crucial to draw a blood culture to identify the causative organism and determine its antibiotic sensitivity. This step is essential in diagnosing osteomyelitis and guiding appropriate antibiotic therapy. Administering antibiotics before obtaining blood cultures can make it more difficult to identify the pathogen, potentially leading to suboptimal treatment.

Think of the blood culture like a detective collecting evidence before a crime scene gets disturbed. It's important to gather all the clues (bacteria) before they get destroyed by the antibiotics.

Accurate and timely diagnosis of osteomyelitis is vital for effective treatment. Blood cultures should be obtained as soon as possible when osteomyelitis is suspected to ensure that the most accurate and effective antibiotic therapy is selected. Following blood culture collection, antibiotics can be administered to begin fighting the infection.

 

✘ Incorrect answer options:

Writing the admission orders. While writing admission orders is important, it does not take priority over obtaining blood cultures in the context of suspected osteomyelitis.

Obtaining a complete blood count with differential. A complete blood count (CBC) with differential is useful for assessing the overall health of the patient and detecting signs of infection, but it is not as critical as obtaining blood cultures before starting antibiotics.

Waiting for the parents to arrive. While involving parents in the care process is important, starting timely medical interventions, such as drawing blood cultures and administering antibiotics, should not be delayed, especially in potential cases of serious infections like osteomyelitis.

 

References

• Kliegman, R. M., St. Geme, J. W., Blum, N. J., Shah, S. S., Tasker, R. C., & Wilson, K. M. (2020). *Nelson Textbook of Pediatrics.* Elsevier.
• Hockenberry, M. J., & Wilson, D. (2019). *Wong's Nursing Care of Infants and Children.* Elsevier.

EXPLANATION

 

✔Correct answer:

Probable signs of pregnancy are objective findings that can be observed by a healthcare provider and suggest, but do not confirm, pregnancy. These signs are more reliable than presumptive signs but are not definitive proof of pregnancy.

Uterine enlargement: This is a probable sign as the uterus increases in size due to the growing fetus. It can be detected through physical examination.

Chadwick’s sign: This refers to the bluish discoloration of the cervix, vagina, and labia resulting from increased blood flow, which can be observed during a pelvic exam.

Braxton Hicks contractions: These are irregular, painless contractions that can begin in the second trimester and are considered a probable sign of pregnancy.

Ballottement: This is a technique used during a pelvic exam where the examiner pushes against the cervix and feels the fetus bounce back. It indicates the presence of a fetus but does not confirm it.

Think of probable signs of pregnancy as clues that point strongly towards pregnancy, like finding pieces of a puzzle. You have most of the pieces (probable signs), but you don’t see the complete picture (confirmation of pregnancy) until all pieces are put together.

Probable signs of pregnancy are critical for early detection and prenatal care planning. They require further confirmation through definitive signs such as fetal heart tones heard via electronic devices or visualization of the fetus via ultrasound. Accurate assessment and timely prenatal care improve maternal and fetal health outcomes.

 

✘Incorrect answer options:

Fetal heart rate detected by a nonelectric device: Detection of fetal heart tones by nonelectric devices (such as a fetoscope) is considered a positive sign of pregnancy, not just a probable sign, as it definitively confirms the presence of a fetus.

Outline of the fetus via radiography or ultrasound: Visualizing the fetus via ultrasound or radiography is a positive sign of pregnancy, providing definitive evidence of the presence of a fetus.

References

• Pillitteri, A. (2018). Maternity Nursing: Care of the Childbearing and Childrearing Family. 8th ed. Lippincott Williams & Wilkins.
• Lowdermilk, D. L., Perry, S. E., Cashion, K., & Alden, K. R. (2016). Maternity & Women's Health Care. 11th ed. Elsevier.

EXPLANATION

 

✔ Correct answer:

Consuming a small glass of warm milk at bedtime. Drinking a small glass of warm milk before bed can promote better sleep. Milk contains tryptophan, an amino acid that the body converts into serotonin and melatonin, hormones that help regulate sleep. The warmth of the milk can also have a soothing effect, which can help relax the body and mind, making it easier to fall asleep.

Think of the warm milk like a cozy blanket for your stomach, helping to make you feel relaxed and ready for sleep.

Establishing a bedtime routine that includes calming activities and avoiding stimulating activities or substances can significantly improve sleep quality. Warm milk is a traditional remedy that many find helpful. Other good sleep hygiene practices include maintaining a consistent sleep schedule, creating a comfortable sleep environment, and avoiding caffeine and heavy meals close to bedtime.

 

✘ Incorrect answer options:

Eating a large meal 1 hour before bedtime. Eating a large meal before bedtime can cause discomfort and indigestion, making it harder to fall asleep. It's generally recommended to have a light snack if needed, rather than a large meal.

Performing mild exercises 30 minutes before going to bed. While regular exercise can promote better sleep, exercising too close to bedtime can be stimulating and make it harder to fall asleep. It's better to finish exercise at least a few hours before bed.

Drinking a glass of wine just before retiring to bed. While alcohol may initially make you feel sleepy, it can disrupt sleep patterns and reduce the quality of sleep. Alcohol can interfere with REM sleep, leading to less restful sleep and frequent awakenings.

 

References

• American Academy of Sleep Medicine. (2021). *Sleep Hygiene Tips.* Retrieved from www.sleepeducation.org.
• National Sleep Foundation. (2021). *Healthy Sleep Tips.* Retrieved from www.sleepfoundation.org.

EXPLANATION

 

✔ Correct answer:

Advise against crossing the legs while seated. Crossing the legs while seated can further impede blood flow in patients with peripheral vascular disease (PVD). This can worsen symptoms and increase the risk of complications such as blood clots. Keeping the legs uncrossed helps to maintain better circulation, which is crucial for managing PVD effectively.

Think of blood vessels as highways. Crossing your legs is like blocking off lanes on the highway, making it harder for traffic (blood) to flow smoothly.

Patients with PVD need to adopt lifestyle modifications that promote blood flow and reduce the risk of complications. This includes avoiding activities that can compress blood vessels, such as crossing the legs, and practicing good foot care to prevent infections and ulcers. Educating patients on these practices can help manage their symptoms and improve their quality of life.

 

✘ Incorrect answer options:

Encourage walking barefoot to improve circulation. Walking barefoot is not recommended for patients with PVD because it increases the risk of injury and infection, particularly if they have neuropathy and cannot feel injuries to their feet.

Recommend using a heating pad to maintain warmth in the feet. Using a heating pad is not advisable because patients with PVD may have reduced sensation in their feet, increasing the risk of burns or thermal injuries. Instead, warm socks can be used to keep feet warm safely.

Suggest applying antibacterial ointment to any skin lesions at risk of infection. While it is important to keep skin lesions clean and prevent infection, the use of antibacterial ointments should be guided by a healthcare provider. Overuse of such ointments can lead to resistance and other complications. Proper wound care and regular monitoring are essential.

 

References

• Hockenberry, M. J., & Wilson, D. (2019). *Wong's Nursing Care of Infants and Children.* Elsevier.
• Kliegman, R. M., St. Geme, J. W., Blum, N. J., Shah, S. S., Tasker, R. C., & Wilson, K. M. (2020). *Nelson Textbook of Pediatrics.* Elsevier.
• American Heart Association. (2021). Understanding Peripheral Artery Disease. Retrieved from www.heart.org.

EXPLANATION

 

✔ Correct answer:

Advising no specific treatment as the fluid is reabsorbing naturally. Hydroceles in infants are typically benign and often resolve on their own within the first year of life. The observation that the scrotum is smaller than at birth and still shows fluid upon illumination indicates that the fluid is gradually being reabsorbed. Physicians generally recommend monitoring the condition without any specific treatment unless the hydrocele persists beyond 12 to 18 months of age or if there are signs of complications.

Think of a hydrocele like a small water balloon that gradually deflates on its own. Over time, the body absorbs the fluid, and the balloon (scrotum) shrinks naturally without the need for intervention.

Hydroceles are common in newborns and usually do not require surgical intervention unless they persist beyond the typical resolution period or are associated with other issues such as inguinal hernias. Parents should be reassured and advised to watch for any signs of pain, discomfort, or changes in the size of the hydrocele that might warrant further evaluation.

 

✘ Incorrect answer options:

Massaging the groin area twice daily to facilitate fluid absorption. Massaging the groin area is not a recommended practice for treating hydroceles and could potentially cause discomfort or harm.

Referring the infant to a surgeon for potential surgical intervention. Surgical intervention is typically not recommended for hydroceles in infants unless they persist beyond 12 to 18 months or are associated with other complications.

Keeping the infant in a flat, supine position to aid fluid reabsorption. Positioning does not significantly influence the natural reabsorption of hydrocele fluid. The condition usually resolves on its own without specific positioning.

 

References

• Hockenberry, M. J., & Wilson, D. (2019). *Wong's Nursing Care of Infants and Children.* Elsevier.
• Kliegman, R. M., St. Geme, J. W., Blum, N. J., Shah, S. S., Tasker, R. C., & Wilson, K. M. (2020). *Nelson Textbook of Pediatrics.* Elsevier.

EXPLANATION

 

✔ Correct answers:

Supine position. The supine position (lying on the back) is the recommended sleeping position for infants to reduce the risk of sudden infant death syndrome (SIDS). Research has consistently shown that placing infants on their backs to sleep significantly decreases the risk of SIDS compared to other positions.

Think of the safest position for a baby like the safest way to drive a car – flat on their back is like having the baby securely buckled up in a car seat, reducing the risk of sudden issues.

The American Academy of Pediatrics (AAP) recommends the supine position as the safest sleep position for infants to reduce SIDS risk. This recommendation is based on extensive studies demonstrating that infants who sleep on their backs have a significantly lower risk of SIDS. Parents should be educated about the importance of back sleeping and advised to avoid placing infants in other positions for sleep unless medically indicated.

 

✘ Incorrect answer options:

Fowler’s position. Fowler’s position (semi-sitting) is not recommended for infant sleep as it does not support the guidelines for safe sleep practices. This position is more suited for feeding or medical purposes rather than sleeping.

Side-lying position. While the side-lying position was once considered acceptable, current guidelines recommend against it due to the possibility of the baby rolling onto their stomach, which increases the risk of SIDS. The supine position remains the safest option.

Prone position. The prone position (lying on the stomach) is associated with a significantly increased risk of SIDS and is not recommended for infant sleep. This position can obstruct the infant’s airway and increase the risk of suffocation.

 

References

• American Academy of Pediatrics. (2016). SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment. Pediatrics, 138(5), e20162938.
• Moon, R. Y., & Task Force on Sudden Infant Death Syndrome. (2016). SIDS and Other Sleep-Related Infant Deaths: Evidence Base for 2016 Updated Recommendations for a Safe Infant Sleeping Environment. Pediatrics, 138(5), e20162940.

EXPLANATION

 

✔ Correct answer:

Torticollis, characterized by the shortening of the sternocleidomastoid muscle. Torticollis, also known as "wry neck," is a condition where the sternocleidomastoid muscle on one side of the neck is shortened, causing the infant to hold their head tilted to one side. This condition can be congenital or acquired and leads to an abnormal head posture. It often results from positioning in the womb or during birth and can be associated with a palpable mass or tightness in the muscle.

Think of the sternocleidomastoid muscle as a rope that has been pulled too tight on one side, causing the head to be pulled in that direction. Just like a tight rope, the shortened muscle needs to be gently stretched and exercised to regain its normal length and function.

Early recognition and intervention for torticollis are crucial. Treatment typically includes physical therapy to gently stretch the shortened muscle and encourage symmetrical neck movement. Parents should be instructed on exercises to perform with the infant and advised on proper positioning during feeding and sleeping to promote muscle lengthening and symmetry.

 

✘ Incorrect answer options:

Craniosynostosis, involving the premature fusion of cranial sutures. Craniosynostosis can cause abnormal head shapes and potential developmental issues but does not specifically cause the head to tilt to one side. It is related to skull growth rather than neck muscle shortening.

Plagiocephaly, indicated by the flattening of one side of the head. Plagiocephaly can result from consistent positioning of the head on one side but typically causes a flat spot rather than an active head tilt. It is more related to skull shape and does not usually involve muscle shortening.

Hydrocephalus, marked by an increased head size. Hydrocephalus involves an abnormal accumulation of cerebrospinal fluid in the brain, leading to increased head size and pressure but does not specifically cause the head to tilt to one side.

 

References

• Hockenberry, M. J., & Wilson, D. (2019). *Wong's Nursing Care of Infants and Children.* Elsevier.
• Kliegman, R. M., St. Geme, J. W., Blum, N. J., Shah, S. S., Tasker, R. C., & Wilson, K. M. (2020). *Nelson Textbook of Pediatrics.* Elsevier.

EXPLANATION

 

✔ Correct answer:

Screening for scoliosis. The forward bend test is a common screening method used to check for scoliosis, a condition characterized by an abnormal lateral curvature of the spine. When the patient bends forward with arms hanging freely, the nurse can observe the symmetry of the back, noting any unevenness or rib hump, which are indicators of scoliosis. This test is particularly useful in identifying spinal deformities in adolescents during routine physical examinations.

Think of the spine as the backbone of a bridge. When looking at the bridge straight on (standing upright), it may appear fine. But if you look from a different angle (bending forward), you can see if any parts are out of alignment, indicating a potential structural issue.

Early detection of scoliosis through screening is important to prevent progression and complications. If scoliosis is detected, further evaluation with radiographic imaging and consultation with a specialist may be necessary. Management options vary depending on the severity of the curvature and may include observation, bracing, or surgical intervention.

 

✘ Incorrect answer options:

Evaluating spinal flexibility. While bending forward can give some indication of spinal flexibility, the specific posture described is more closely associated with scoliosis screening rather than a general assessment of flexibility.

Checking for leg length disparities. Leg length discrepancies are typically assessed with the patient lying down or standing upright, not in a forward-bend position.

Measuring hypostatic blood pressure. Hypostatic (orthostatic) blood pressure is assessed by measuring blood pressure changes when the patient moves from lying down to a standing position, not during a forward bend.

 

References

• Hockenberry, M. J., & Wilson, D. (2019). *Wong's Nursing Care of Infants and Children.* Elsevier.
• Kliegman, R. M., St. Geme, J. W., Blum, N. J., Shah, S. S., Tasker, R. C., & Wilson, K. M. (2020). *Nelson Textbook of Pediatrics.* Elsevier.

EXPLANATION

 

✔ Correct answers:

It occurs when the oxygen demand exceeds the oxygen supply to the muscles. Claudication occurs when the muscles require more oxygen during activity, but due to narrowed or blocked arteries (as seen in peripheral vascular disease), the blood flow and thus the oxygen supply is insufficient to meet the increased demand.

It results from tissue hypoxia due to inadequate blood flow. The inadequate blood flow caused by narrowed arteries leads to tissue hypoxia (lack of oxygen), which is the underlying cause of the pain associated with claudication.

It manifests as cramping and weakness in the affected limbs. Claudication commonly presents as cramping, pain, and weakness in the affected muscles, typically the calves, thighs, or buttocks, during physical activity. The pain is relieved with rest.

Think of claudication like trying to run while breathing through a straw. The muscles (like your lungs in this analogy) need more oxygen, but the narrow straw (blocked arteries) can't supply enough, leading to pain and cramping.

Claudication is a key symptom of peripheral vascular disease, indicating significant arterial insufficiency. Understanding its mechanisms helps in recognizing the severity of the condition and guiding appropriate interventions, such as encouraging smoking cessation, exercise, and potentially medical or surgical treatments to improve blood flow.

 

✘ Incorrect answer option:

It is marked by pain that typically occurs during periods of rest. Claudication pain occurs during physical activity when the demand for oxygen increases. The pain typically subsides with rest, as the oxygen demand decreases and the limited blood flow becomes sufficient to meet the muscles' needs.

 

References

• Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 10th ed. Elsevier.
• Norgren, L., Hiatt, W. R., Dormandy, J. A., Nehler, M. R., Harris, K. A., & Fowkes, F. G. R. (2007). Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Journal of Vascular Surgery, 45(1), S5-S67.

EXPLANATION

 

✔Correct answer:

Pulmonary embolism, possibly resulting from deep vein thrombosis (DVT). A pulmonary embolism (PE) is the most likely cause of sudden shortness of breath and chest pain in a pregnant patient on prolonged bed rest. Pregnancy increases the risk of thrombosis due to hypercoagulability, and bed rest exacerbates this risk by causing venous stasis. A PE occurs when a blood clot, often originating in the deep veins of the legs (DVT), travels to the lungs, blocking a pulmonary artery. This condition is a medical emergency requiring immediate attention.

Think of a river flowing smoothly, but if debris forms a dam, the water upstream backs up and overflows. Similarly, a blood clot blocking a pulmonary artery prevents blood flow to the lungs, causing symptoms like shortness of breath and chest pain.

During pregnancy, the body undergoes several changes that increase the risk of clot formation. These include increased levels of clotting factors, decreased fibrinolysis (the process that breaks down clots), and venous stasis due to the pressure of the growing uterus on pelvic veins. Bed rest further reduces blood flow in the legs, increasing the likelihood of DVT. When a clot from the leg travels to the lungs and blocks a pulmonary artery, it leads to a PE, presenting with symptoms such as acute dyspnea, chest pain, tachycardia, and possibly hemoptysis.

 

✘Incorrect answer options:

Myocardial infarction, influenced by pre-existing atherosclerosis. While a myocardial infarction (MI) can cause chest pain and shortness of breath, it is less likely in a young, 24-year-old pregnant woman without known risk factors for atherosclerosis. MI typically involves severe chest pain radiating to the arm or jaw and is often accompanied by nausea, sweating, and a feeling of impending doom.

Anxiety attack, triggered by concerns about her baby's health. An anxiety attack can cause symptoms like shortness of breath and chest pain. However, in the context of a pregnant woman on prolonged bed rest, it is crucial to first rule out more serious conditions such as a pulmonary embolism before considering anxiety as the cause. Anxiety attacks also generally include other symptoms like palpitations, dizziness, and tingling sensations.

Congestive heart failure, potentially caused by fluid overload. Congestive heart failure (CHF) can cause shortness of breath and chest discomfort, but it is less common in young, otherwise healthy pregnant women. CHF symptoms typically include edema, fatigue, and orthopnea (difficulty breathing when lying flat), which are not specifically mentioned in this scenario.

 

References

• Hinkle, J. L., & Cheever, K. H. (2017). *Brunner & Suddarth's Textbook of Medical-Surgical Nursing*. Wolters Kluwer.
• Lowdermilk, D. L., Perry, S. E., Cashion, K., & Alden, K. R. (2016). *Maternity and Women's Health Care*. Elsevier Health Sciences.

EXPLANATION

 

✔Correct answer:

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the initial treatment choice. NSAIDs are commonly used as the first line of treatment for juvenile idiopathic arthritis (JIA). These medications help to reduce inflammation, alleviate pain, and improve joint function. Examples of NSAIDs used in JIA include ibuprofen and naproxen. They are generally well-tolerated and effective in managing the symptoms of JIA in many children.

Think of NSAIDs like firefighters arriving first on the scene of a small fire. They help control and reduce the flames quickly to prevent further damage, much like how NSAIDs control inflammation and pain in JIA.

NSAIDs work by inhibiting the enzymes cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2), which play a key role in the production of prostaglandins. Prostaglandins are lipid compounds that contribute to inflammation, pain, and fever. By reducing prostaglandin levels, NSAIDs help decrease inflammation and pain, providing symptomatic relief for children with JIA. Early and effective management with NSAIDs can improve the quality of life for children and potentially prevent long-term complications.

 

✘Incorrect answer options:

The child is unlikely to recover without some form of joint deformity. While joint deformities can occur in severe or untreated cases of JIA, many children respond well to treatment and can lead active, healthy lives without significant joint deformities. Early diagnosis and appropriate treatment are crucial in preventing long-term damage.

Most children with this condition will develop adult rheumatoid arthritis. This statement is inaccurate. Many children with JIA do not go on to develop adult rheumatoid arthritis. JIA is a distinct condition, and while some individuals may experience ongoing symptoms into adulthood, many achieve remission or have significantly reduced disease activity.

Physical activity should be kept to a minimum. This is incorrect as well. Regular physical activity is actually encouraged for children with JIA to maintain joint function, muscle strength, and overall physical health. Exercise programs should be tailored to the child's abilities and limitations, but complete inactivity can lead to muscle weakness and joint stiffness.

 

References

• Petty, R. E., Laxer, R. M., Lindsley, C. B., & Wedderburn, L. R. (2016). *Textbook of Pediatric Rheumatology*. Elsevier.
• Kleigman, R. M., St. Geme, J. W., Blum, N. J., Shah, S. S., Tasker, R. C., & Wilson, K. M. (2019). *Nelson Textbook of Pediatrics*. Elsevier.

EXPLANATION

 

✔ Correct answer:

A recent infection with group A Streptococcus occurring 10-14 days prior. The most common cause of acute glomerulonephritis, particularly in children, is a recent infection with group A Streptococcus. This type of infection typically involves the throat (pharyngitis) or skin (impetigo). The immune response to the streptococcal infection can lead to the formation of immune complexes, which become trapped in the glomeruli of the kidneys, causing inflammation and impaired kidney function. Symptoms of acute glomerulonephritis usually appear 10-14 days after the initial streptococcal infection.

Think of the kidneys as coffee filters. When there's an infection, the immune system's response creates "clumps" that clog the filters, causing them to work improperly. This is similar to how immune complexes clog the glomeruli after a streptococcal infection.

Post-streptococcal glomerulonephritis (PSGN) is an important diagnosis to consider in patients presenting with hematuria, proteinuria, edema, and hypertension following a recent streptococcal infection. Early recognition and appropriate management, including supportive care and monitoring of renal function, are crucial. Patients may require hospitalization for severe cases, especially if there are significant renal impairments or complications such as hypertensive encephalopathy.

 

✘ Incorrect answer options:

A congenital anomaly that results in renal dysfunction. Congenital anomalies can lead to chronic kidney issues but are not the most common cause of acute glomerulonephritis. Acute glomerulonephritis is typically triggered by an immune response to an infection rather than a congenital defect.

A viral infection directly involving the glomeruli. While certain viral infections can cause glomerulonephritis, they are less common causes compared to post-streptococcal glomerulonephritis. Examples include hepatitis B and C, but these are not the most frequent triggers.

An underlying case of nephrotic syndrome. Nephrotic syndrome is a different renal condition characterized by severe proteinuria, hypoalbuminemia, and edema. While it can coexist with glomerulonephritis, it is not a common cause of acute glomerulonephritis. Nephrotic syndrome can result from glomerulonephritis but is not the usual precursor.

 

References

• Hockenberry, M. J., & Wilson, D. (2019). *Wong's Nursing Care of Infants and Children.* Elsevier.
• Kliegman, R. M., St. Geme, J. W., Blum, N. J., Shah, S. S., Tasker, R. C., & Wilson, K. M. (2020). *Nelson Textbook of Pediatrics.* Elsevier.

EXPLANATION

 

✔ Correct answer:

A young woman. Raynaud's disease, also known as Raynaud's phenomenon, primarily affects young women, typically between the ages of 15 and 30. It is characterized by episodes of vasospasm, leading to reduced blood flow to the extremities, most commonly the fingers and toes. These episodes are often triggered by cold exposure or emotional stress, causing the affected areas to turn white or blue and feel cold and numb. Once blood flow returns, the areas may turn red and become painful.

Imagine your fingers as water pipes in a house. In young women with Raynaud's disease, the pipes (blood vessels) can suddenly tighten and narrow when it's cold or stressful, just like pipes freezing in winter. This causes the water (blood) to slow down or stop, making the pipes feel cold and stiff. When the pipes warm up, the water flows again, sometimes with a sudden rush, causing discomfort as things return to normal. Young women are particularly affected due to hormonal influences that make their blood vessels more reactive to cold and stress.

Understanding the demographic most affected by Raynaud's disease helps tailor patient education and management strategies. Young women with this condition should be advised to keep their hands and feet warm, avoid triggers such as smoking and stress, and consider using medications if symptoms are severe. Nurses should also educate patients on the importance of protecting their extremities from cold and injury to prevent complications.

 

✘ Incorrect answer options:

An adolescent male. While Raynaud's disease can affect males, it is significantly more common in young women. Adolescent males are not the primary demographic for this condition.

An elderly woman. Although Raynaud's can occur in older individuals, it is more commonly diagnosed in younger women. The onset of symptoms typically occurs earlier in life.

An elderly man. Raynaud's disease is less common in elderly men compared to young women. The primary demographic affected by this condition is young women.

 

References

• Kliegman, R. M., St. Geme, J. W., Blum, N. J., Shah, S. S., Tasker, R. C., & Wilson, K. M. (2020). *Nelson Textbook of Pediatrics.* Elsevier.
• Petri, M., & Orbai, A. M. (2021). *Raynaud’s Phenomenon*. Johns Hopkins Medicine. Retrieved from www.hopkinsmedicine.org.

EXPLANATION

 

✔ Correct answers:

It's crucial to have regular developmental screenings to prevent or address secondary developmental delays. Regular developmental screenings are essential for early identification and intervention of secondary delays or complications. Early detection allows for timely therapeutic interventions that can significantly improve outcomes for children with cerebral palsy.

Cerebral palsy is due to injury to the upper motor neurons, leading to motor dysfunction and may also involve difficulties with vision and speech. Cerebral palsy is a neurological disorder caused by damage to the brain's motor control centers. This damage leads to motor dysfunction, which can be accompanied by other issues such as visual impairments and speech difficulties. Understanding the comprehensive nature of the condition helps parents manage and seek appropriate therapies.

Joining parent support groups can be beneficial for exchanging strategies and managing health care issues related to cerebral palsy. Support groups provide a valuable resource for parents, offering emotional support, shared experiences, and practical advice on managing the complexities of cerebral palsy. These groups can help parents feel less isolated and more empowered in their caregiving roles.

Managing cerebral palsy is like assembling a puzzle. Each piece (screenings, understanding the condition, and support groups) is crucial to see the whole picture and provide comprehensive care for the child.

Cerebral palsy is a lifelong condition requiring a multidisciplinary approach to care. Regular screenings, understanding the full spectrum of potential complications, and seeking support are fundamental strategies for optimizing the child's development and quality of life. These elements form the cornerstone of a proactive management plan, enabling parents to provide the best possible care for their child.

 

✘ Incorrect answer option:

Developmental milestones might be slightly delayed, but generally do not require further intervention. This statement is incorrect as children with cerebral palsy often require ongoing interventions to support their development. Delayed milestones typically necessitate targeted therapies, such as physical, occupational, and speech therapy, to help the child achieve their fullest potential.

 

References

• Rosenbaum, P., Paneth, N., Leviton, A., Goldstein, M., Bax, M., Damiano, D., ... & Jacobsson, B. (2007). A report: the definition and classification of cerebral palsy April 2006. Developmental Medicine & Child Neurology, 49(s109), 8-14.
• Himmelmann, K., & Uvebrant, P. (2011). The panorama of cerebral palsy in Sweden. III. The dynamics of cerebral palsy. Acta Paediatrica, 100(7), 1010-1015.

EXPLANATION

 

✔Correct answer:

Chronic renal failure, also known as chronic kidney disease (CKD), involves the gradual loss of kidney function over time. The kidneys play a crucial role in fluid and electrolyte balance, waste removal, and several metabolic processes. As kidney function declines, several common problems arise, leading to specific nursing diagnoses.

Excess Fluid Volume: In CKD, the kidneys' ability to excrete fluids is impaired, leading to fluid retention. This can cause edema, hypertension, and heart failure. Monitoring fluid intake and output, assessing for signs of fluid overload, and implementing fluid restrictions are critical nursing interventions.

Imbalanced Nutrition: Less than Body Requirements: Clients with CKD often experience anorexia, nausea, and dietary restrictions, leading to inadequate nutritional intake. They may also have protein-energy malnutrition due to the disease process and dietary limitations to reduce the workload on the kidneys. Providing nutritional support and collaborating with a dietitian are essential aspects of care.

Activity Intolerance: Fatigue and decreased physical endurance are common in CKD due to anemia, uremia, and overall decline in health. Encouraging gradual activity and providing rest periods can help manage this issue.

Think of the kidneys as a water filter in a fish tank. If the filter is not working well, the water (body fluids) gets murky (fluid overload), the fish don’t get the right nutrients (imbalanced nutrition), and the fish might not swim as actively (activity intolerance).

Managing a client with CKD involves a holistic approach, considering physical, nutritional, and psychosocial aspects. Regular assessment of fluid status, electrolyte balance, and nutritional intake is crucial. Collaboration with the healthcare team, including dietitians and physical therapists, enhances the quality of care. Addressing anemia and other complications through medication and dietary modifications is also vital.

 

✘Incorrect answer options:

Impaired Gas Exchange: This diagnosis is more specific to respiratory conditions where there is a direct impairment in the exchange of oxygen and carbon dioxide. While CKD can lead to respiratory issues like pulmonary edema, it is not the most direct or common issue compared to the fluid and metabolic imbalances.

Pain: Although pain can be a component of CKD, especially if there are comorbid conditions like peripheral neuropathy or bone pain from renal osteodystrophy, it is not as universally prevalent or directly related to the primary pathophysiology of CKD as the other selected diagnoses.

References

• Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2020). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 11th ed. Elsevier.
• Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. 14th ed. Wolters Kluwer.

EXPLANATION

 

✔ Correct answer:

The tumor extended beyond the kidney but has been completely removed. Stage II of Wilms' tumor indicates that the tumor has extended beyond the kidney, but it has been completely removed with surgery. This stage signifies that the cancer cells may have invaded the surrounding soft tissue or blood vessels but have not spread to distant sites. The prognosis for stage II Wilms' tumor is generally good, especially with appropriate treatment, which typically includes surgery followed by chemotherapy, and sometimes radiation therapy.

Imagine a small tree that has grown slightly outside its designated garden area but has been fully dug up and removed. Even though it spread a bit, it has been entirely taken out, and measures will be taken to ensure no roots are left behind.

Wilms' tumor is a type of kidney cancer that primarily affects children. Staging helps determine the extent of the tumor and guides the treatment plan. Stage II tumors require a comprehensive treatment approach to address any potential microscopic residual disease and reduce the risk of recurrence. Educating parents about the stage and treatment plan helps them understand the prognosis and the importance of follow-up care.

 

✘ Incorrect answer options:

The tumor measures less than 3 cm and does not require chemotherapy. Tumor size alone does not determine the stage, and most cases of Wilms' tumor, regardless of size, do require chemotherapy to prevent recurrence and ensure all cancer cells are eliminated.

The tumor was confined to the kidney and has been completely removed. This describes stage I of Wilms' tumor, where the cancer is localized to the kidney and has been fully resected without any spread beyond the kidney.

The tumor has spread into the abdominal cavity and is non-resectable. This description aligns more with stage III or IV, where the tumor has spread extensively and may not be fully removable. Stage III tumors have residual non-hematogenous tumor confined to the abdomen, while stage IV indicates hematogenous metastasis (spread to distant organs).

 

References

• Hockenberry, M. J., & Wilson, D. (2019). *Wong's Nursing Care of Infants and Children.* Elsevier.
• Kliegman, R. M., St. Geme, J. W., Blum, N. J., Shah, S. S., Tasker, R. C., & Wilson, K. M. (2020). *Nelson Textbook of Pediatrics.* Elsevier.

EXPLANATION

 

✔ Correct answer:

Insufficient tissue perfusion resulting in nerve damage. Peripheral vascular disease (PVD) leads to reduced blood flow to the extremities due to narrowed or blocked blood vessels. This insufficient tissue perfusion can cause nerve damage, leading to symptoms such as burning, tingling sensations, and hypersensitivity to touch. When tissues and nerves do not receive adequate oxygen and nutrients, they can become damaged, causing these discomforting symptoms.

Imagine a garden hose that's kinked and not delivering enough water to your plants. The plants (nerves) start to wilt and show signs of distress (burning and tingling) because they're not getting the nourishment they need.

Managing PVD involves improving blood flow to the affected areas through lifestyle changes, medications, and sometimes surgical interventions. Patients should be encouraged to engage in regular, moderate exercise, maintain a healthy diet, and avoid smoking. Pain and discomfort can be managed with medications and therapies aimed at improving circulation and nerve health. Regular monitoring and follow-up are essential to prevent complications and improve quality of life.

 

✘ Incorrect answer options:

Fluid retention causing pressure on nerve tissues. While fluid retention can cause pressure on nerves, it is not the most likely cause of the burning and tingling sensations in PVD. The primary issue in PVD is poor blood flow, not fluid retention.

Altered sensation related to a psychiatric condition. While psychiatric conditions can cause somatic symptoms, the burning and tingling sensations in a patient with PVD are more likely due to physical nerve damage from poor circulation rather than a psychiatric issue.

Inflammatory reactions in the skin of the hands and feet. Inflammatory reactions can cause skin symptoms, but they are not the primary cause of the burning and tingling sensations associated with PVD. The key issue is inadequate blood flow leading to nerve damage.

 

References

• Hockenberry, M. J., & Wilson, D. (2019). *Wong's Nursing Care of Infants and Children.* Elsevier.
• Kliegman, R. M., St. Geme, J. W., Blum, N. J., Shah, S. S., Tasker, R. C., & Wilson, K. M. (2020). *Nelson Textbook of Pediatrics.* Elsevier.

EXPLANATION

 

✔ Correct answers:

Ensure the client is in proper body alignment. Proper body alignment can help facilitate the flow of dialysate. Misalignment can obstruct the flow, leading to an imbalance between inflow and outflow.

Check the level of the drainage bag. The drainage bag should be positioned lower than the client’s abdomen to use gravity to aid the drainage process. If the bag is too high, it may impede the outflow.

Inspect the peritoneal dialysis system for any kinks. Kinks or obstructions in the tubing can block the flow of dialysate, leading to decreased outflow. Ensuring that the system is free of kinks is essential for proper function.

Reposition the client to their side. Repositioning the client can help resolve issues with the flow of dialysate by shifting the catheter tip away from the peritoneal wall or other internal structures that might be blocking the flow.

Think of the peritoneal dialysis system like a garden hose. Ensuring proper alignment (straightening the hose), checking for kinks, and repositioning the hose can all help ensure a smooth flow of water (dialysate).

When monitoring peritoneal dialysis, it is crucial to ensure that the system functions optimally to prevent complications such as fluid retention or infection. Addressing issues with outflow promptly by checking for common mechanical problems can often resolve the issue without needing to escalate care immediately.

 

✘ Incorrect answer option:

Contact the physician. While it may be necessary to contact the physician if the issue persists or if there are signs of complications, it is not the first step. Initial troubleshooting steps include ensuring proper body alignment, checking the drainage bag level, inspecting the system for kinks, and repositioning the client.

 

References

• Alexander, M., Corrigan, A., Gorski, L., Hankins, J., & Perucca, R. (2010). Infusion Nursing: An Evidence-Based Approach. Saunders.
• Counts, C. S. (2015). Core Curriculum for Nephrology Nursing. 6th ed. American Nephrology Nurses Association.

EXPLANATION

 

✔ Correct answer:

A possible fracture of the tibia. Given the child's refusal to walk and the presence of swelling in the lower leg, the most likely cause of the symptoms is a possible fracture of the tibia. In young children, fractures can occur with relatively low-impact injuries, and refusal to bear weight or walk is a common sign of a fracture in the lower extremities. Swelling in the area further supports the likelihood of a fracture.

Imagine a tree branch that gets cracked. If you try to bend or use it, it hurts, and you can see swelling or changes around the crack. Similarly, a child's tibia might be cracked (fractured), causing pain and swelling, and the child avoids using it by refusing to walk.

In pediatric patients, fractures should be suspected when there is a refusal to bear weight, localized swelling, and pain following an injury. Tibial fractures are common in toddlers due to their active nature and the high impact on their legs during falls or minor accidents. X-rays and further imaging studies are typically warranted to confirm the diagnosis and guide treatment.

 

✘ Incorrect answer options:

Bruising of the gastrocnemius muscle. While bruising can cause pain and swelling, it is less likely to cause a child to completely refuse to walk unless it is severe. The symptoms described are more consistent with a fracture.

A possible fracture of the radius. A fracture of the radius would affect the arm, not the leg. Since the symptoms are in the lower leg and the child refuses to walk, a radius fracture is not relevant.

No anatomical injury; the child desires to be carried by his mother. While it's possible for children to seek attention or comfort from their parents, the presence of swelling in the lower leg suggests a genuine anatomical injury rather than a behavioral issue.

 

References

• Hockenberry, M. J., & Wilson, D. (2019). *Wong's Nursing Care of Infants and Children.* Elsevier.
• Kliegman, R. M., St. Geme, J. W., Blum, N. J., Shah, S. S., Tasker, R. C., & Wilson, K. M. (2020). *Nelson Textbook of Pediatrics.* Elsevier.

EXPLANATION

 

✔Correct answer:

Duchenne's is an X-linked recessive disorder, so daughters have a 50% chance of being carriers and sons a 50% chance of developing the disease.  Duchenne muscular dystrophy (DMD) is inherited in an X-linked recessive pattern. This means the gene responsible for DMD is located on the X chromosome. Males have one X and one Y chromosome (XY), while females have two X chromosomes (XX). Since males only have one X chromosome, if they inherit the X chromosome carrying the defective gene from their mother, they will develop the disease. Females, on the other hand, must inherit two copies of the defective gene (one from each parent) to develop the disease, which is rare. Typically, females with one defective gene are carriers and may pass the gene to their offspring.

Think of the X chromosome as a pair of shoes. If a boy has only one pair, and one shoe is broken, he has no spare and will stumble (develop the disease). A girl has two pairs; if one shoe is broken, she can still walk well (be a carrier) because she has a spare.

In DMD, the defective gene on the X chromosome affects the production of dystrophin, a protein essential for muscle fiber strength and integrity. Without dystrophin, muscle cells become damaged and weaken over time, leading to the progressive muscle degeneration seen in DMD. Since males have only one X chromosome, the presence of the defective gene results in the disease. Females with one defective gene usually do not show symptoms because their other X chromosome typically carries a functional gene.

 

✘Incorrect answer options:

Duchenne’s is an X-linked recessive disorder, so both daughters and sons have a 50% chance of developing the disease. This statement is incorrect because daughters typically do not develop the disease unless they inherit two defective genes, which is very rare. Sons have a 50% chance of developing the disease if their mother is a carrier.

Each child has a 1 in 4 (25%) chance of developing the disorder. This statement would be true for an autosomal recessive disorder, not an X-linked recessive disorder. In X-linked recessive inheritance, the chances differ between sons and daughters.

Sons only have a 1 in 4 (25%) chance of developing the disorder. This statement is incorrect because sons have a 50% chance of inheriting the defective gene from a carrier mother and thus developing the disease, not 25%.

 

References

• Thompson, M. W., & Thompson, J. S. (2016). *Thompson & Thompson Genetics in Medicine*. Elsevier.
• Porth, C. M. (2014). *Essentials of Pathophysiology: Concepts of Altered Health States*. Lippincott Williams & Wilkins.

EXPLANATION

 

✔Correct answer:

Cerebral hemorrhage. Thrombolytic therapy, such as the administration of tissue plasminogen activator (tPA), is used to dissolve blood clots in patients with acute ischemic stroke. However, this treatment carries a significant risk of causing cerebral hemorrhage, which is bleeding within the brain. The breakdown of the clot can weaken blood vessels, leading to a rupture and subsequent bleeding. This risk is especially pertinent in patients with certain conditions such as uncontrolled hypertension or recent history of bleeding.

Imagine using a powerful chemical to dissolve a stubborn clog in a pipe. While the chemical can clear the blockage, it might also damage the pipe itself, causing leaks. Similarly, thrombolytic therapy can dissolve clots but may also damage blood vessels, leading to bleeding.

Thrombolytic agents work by activating plasminogen to plasmin, which then degrades fibrin and dissolves clots. This process is essential for restoring blood flow in ischemic stroke but can also affect other fibrin structures, including those in blood vessels. The risk of hemorrhage is heightened due to the potential for the therapy to disrupt the integrity of blood vessel walls, particularly in the brain, where vessels are delicate and tightly regulated.

 

✘Incorrect answer options:

Air embolism. Air embolism is a rare complication that occurs when air enters the bloodstream, typically due to invasive procedures like surgery or central line placement. It is not associated with thrombolytic therapy.

Expansion of the clot. The purpose of thrombolytic therapy is to dissolve clots, not expand them. Therefore, clot expansion is not a risk associated with this treatment. Instead, the concern is the potential for bleeding complications as the clot is dissolved.

Resolution of the clot. Resolution of the clot is the intended effect of thrombolytic therapy and not a complication. The goal is to restore blood flow by dissolving the obstructing clot, which alleviates ischemia in the affected area of the brain.

 

References

• Hinkle, J. L., & Cheever, K. H. (2017). *Brunner & Suddarth's Textbook of Medical-Surgical Nursing*. Wolters Kluwer.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). *Medical-Surgical Nursing: Assessment and Management of Clinical Problems*. Elsevier.

EXPLANATION

 

✔Correct answer:

Autonomic dysreflexia (AD) is a potentially life-threatening condition that occurs in individuals with spinal cord injuries at or above the T6 level. It is characterized by uncontrolled hypertension and is triggered by a noxious stimulus below the level of the injury.

Elevate the head of the bed to 90 degrees: Raising the head of the bed helps to lower blood pressure by promoting venous pooling of blood in the lower extremities, reducing the return of blood to the heart and thereby decreasing overall blood pressure.

Loosen any tight clothing: Tight clothing can be a triggering factor for AD as it may act as a noxious stimulus. Loosening clothing reduces any external pressure and helps alleviate the condition.

Assess for bladder distention and bowel impaction: Common triggers for AD include bladder distention and bowel impaction. Assessing and addressing these issues can help resolve the hypertensive crisis.

Administer antihypertensive medication if needed: If non-pharmacological interventions do not promptly reduce blood pressure, administering antihypertensive medication can be necessary to manage severe hypertension and prevent complications such as stroke.

Think of autonomic dysreflexia as a pressure cooker that is overheated due to a blockage. Elevating the head of the bed is like releasing the pressure valve, loosening clothing removes any extra pressure, and checking the bladder and bowel is like ensuring the cooker is not blocked and functioning properly.

Immediate and effective management of AD is critical to prevent severe complications. Nurses must act quickly to identify and eliminate the triggering stimulus while also monitoring the client’s blood pressure and symptoms. Education on the recognition and prevention of AD is essential for both clients and caregivers.

 

✘Incorrect answer options:

Use a fan to help reduce sweating: While reducing sweating may provide comfort, it does not address the underlying cause of AD and is not an appropriate primary intervention.

Place the client in a supine position with legs elevated: This position could exacerbate hypertension by increasing venous return to the heart, further elevating blood pressure and worsening the AD episode.

References

• Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2020). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 11th ed. Elsevier.
• Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. 14th ed. Wolters Kluwer.

EXPLANATION

 

✔ Correct answer:

Self-blame for the child's injuries. Parents who abuse their children are least likely to exhibit self-blame for the child's injuries. In many cases, abusive parents may rationalize or deny their actions, attributing the cause of injuries to accidents or external factors rather than acknowledging their role. They may lack insight into their behavior and its impact on the child, often blaming the child or external circumstances instead of taking responsibility.

Imagine someone who keeps breaking things in their house but always says it was an accident or someone else’s fault. They rarely admit that their own carelessness or behavior caused the damage.

Understanding the psychological profile of abusive parents can help healthcare professionals identify and intervene in cases of child abuse more effectively. Characteristics such as low self-esteem, unemployment, and being a single parent are more commonly observed in abusive parents and can be contributing factors to the stress and frustration that may lead to abusive behavior. Recognizing these signs allows for targeted support and intervention strategies to protect the child and address the underlying issues in the family.

 

✘ Incorrect answer options:

Low self-esteem. Abusing parents often struggle with low self-esteem, which can contribute to their inability to manage stress and frustration effectively, sometimes resulting in abusive behavior.

Unemployment. Unemployment can increase stress and frustration in a family, potentially leading to abusive behavior. It is a common characteristic observed in abusive parents due to the financial and emotional pressures it creates.

Being a single parent. Single parenting can be associated with increased stress and limited support systems, factors that may contribute to the likelihood of abusive behavior. While not all single parents are abusive, it is a risk factor that can be observed in such cases.

 

References

• American Academy of Pediatrics. (2019). Understanding Child Abuse and Neglect. Retrieved from www.aap.org.
• Hockenberry, M. J., & Wilson, D. (2019). *Wong's Nursing Care of Infants and Children.* Elsevier.