CATEGORY 1
A patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. Which of the following are hereditary risk factors for developing atherosclerosis?
Correct Answer: A. Family history of heart disease.
A family history of heart disease is an inherited risk factor that is not subject to a lifestyle change. Having a first-degree relative with heart disease has been shown to significantly increase risk.
Thrombolytic therapy is frequently used in the treatment of suspected stroke. Which of the following is a significant complication associated with thrombolytic therapy?
Correct Answer: B. Cerebral hemorrhage.
Cerebral hemorrhage is a significant risk when treating a stroke victim with thrombolytic therapy intended to dissolve a suspected clot. The success of the treatment demands that it be instituted as soon as possible, often before the cause of stroke has been determined.
A nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has just been diagnosed with juvenile idiopathic arthritis. Which of the following statements about the disease is most accurate?
Correct Answer: C. Nonsteroidal anti-inflammatory drugs are the first choice in treatment.
Nonsteroidal anti-inflammatory drugs are an important first-line treatment for juvenile idiopathic arthritis (formerly known as juvenile rheumatoid arthritis). NSAIDs require 3-4 weeks for the therapeutic anti-inflammatory effects to be realized.
A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the
Correct Answer: C. Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow
PTCA is performed to improve coronary artery blood flow in a diseased artery. It is performed during a cardiac catheterization. Aorta coronary bypass graft is the surgical procedure to repair a diseased coronary artery.
A 3-year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should:
Correct Answer: A. Expose the cast to air and turn the child frequently
The child should be turned every 2 hours, with the surface exposed to the air. Casts and splints hold the bones in place while they heal. They also reduce pain, swelling, and muscle spasm.
Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? Select all that apply:
Correct Answer: A, C, & D.
Claudication describes the pain experienced by a patient with a peripheral vascular disease when oxygen demand in the leg muscles exceeds the oxygen supply. The tissue becomes hypoxic, causing cramping, weakness, and discomfort.
An infant is brought to the clinic by his mother, who has noticed that he holds his head in an unusual position and always faces to one side. Which of the following is the most likely explanation?
Correct Answer: A. Torticollis, with shortening of the sternocleidomastoid muscle.
In torticollis, the sternocleidomastoid muscle is contracted, limiting the range of motion of the neck and causing the chin to point to the opposing side.
A child is admitted to the hospital several days after stepping on a sharp object that punctured her athletic shoe and entered the flesh of her foot. The physician is concerned about osteomyelitis and has ordered parenteral antibiotics. Which of the following actions is done immediately before the antibiotic is started?
Correct Answer: B. A blood culture is drawn.
Antibiotics must be started after the blood culture is drawn, as they may interfere with the identification of the causative organism.
A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize:
Correct Answer: B. Administration of thyroid hormone will prevent problems.
Early identification and continued treatment with hormone replacement correct this condition.
A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would:
Correct Answer: C. Administer a laxative to the client the evening before the examination
Bowel prep is important because it will allow greater visualization of the bladder and ureters. Intravenous pyelogram (IVP) is an x-ray exam that uses an injection of contrast material to evaluate the kidneys, ureters, and bladder and help diagnose blood in the urine or pain in the side or lower back. An IVP may provide enough information to allow the doctor to treat with medication and avoid surgery.
A nurse is providing discharge information to a patient with peripheral vascular disease. Which of the following information should be included in the instructions?
Correct Answer: C. Avoid crossing the legs.
Patients with peripheral vascular disease should avoid crossing the legs because this can impede blood flow. PVD, also known as arteriosclerosis obliterans, is primarily the result of atherosclerosis. The atheroma consists of a core of cholesterol joined to proteins with a fibrous intravascular covering. The atherosclerotic process may gradually progress to complete occlusion of medium-sized and large arteries. The disease typically is segmental, with significant variation from patient to patient.
An adolescent brings a physician’s note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?
Correct Answer: C. The student experiences pain in the inferior aspect of the knee.
Osgood-Schlatter disease occurs in adolescents in the rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly caused by activities that require repeated use of the quadriceps, including track and soccer.
A two-year-old child has sustained an injury to the leg and refuses to walk. The nurse in the emergency department documents swelling of the lower affected leg. Which of the following does the nurse suspect is the cause of the child’s symptoms?
Correct Answer: A. Possible fracture of the tibia.
The child’s refusal to walk, combined with swelling of the limb is suspicious for fracture.
A priority goal of involuntary hospitalization of the severely mentally ill client is
Correct Answer: C. Protection from self-harm and harm to others.
Involuntary hospitalization may be required for persons considered dangerous to self or others or for individuals who are considered gravely disabled.
Following a diagnosis of acute glomerulonephritis (AGN) in their 6-year-old child, the parent’s remark: “We just don’t know how he caught the disease!” The nurse’s response is based on an understanding that:
Correct Answer: D. It is not “caught” but is a response to a previous B-hemolytic strep infection.
AGN is generally accepted as an immune-complex disease in relation to an antecedent streptococcal infection of 4 to 6 weeks prior and is considered as a noninfectious renal disease.
A patient who has been diagnosed with the vasospastic disorder (Raynaud’s disease) complains of cold and stiffness in the fingers. Which of the following descriptions is most likely to fit the patient?
Correct Answer: C. young woman.
Raynaud’s disease is most common in young women and is frequently associated with rheumatologic disorders, such as lupus and rheumatoid arthritis. Vasospasm of the arteries reduces blood flow to the fingers and toes. In people who have Raynaud’s, the disorder usually affects the fingers. In about 40 percent of people who have Raynaud’s, it affects the toes. Rarely, the disorder affects the nose, ears, nipples, and lips.
The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?
Correct Answer: D. Scoliosis.
A check for scoliosis, a lateral deviation of the spine, is an important part of the routine adolescent exam. It is assessed by having the teen bend at the waist with arms dangling, while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents.
A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Select all that apply.
Correct Answer: A, B, and D.
Delayed developmental milestones are characteristic of cerebral palsy, so regular screening and intervention is essential. Because of injury to upper motor neurons, children may have ocular and speech difficulties. Parent support groups help families to share and cope. Physical therapy and other interventions can minimize the extent of the delay in developmental milestones.
A 19-year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of “suppression”?
Correct Answer: A. “I don’t remember anything about what happened to me.”
Suppression is willfully putting an unacceptable thought or feeling out of one’s mind. A deliberate exclusion “voluntary forgetting” is generally used to protect one’s own self-esteem.
The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3-day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the healthcare provider immediately?
Correct Answer: D. No measurable voiding in 4 hours.
The concern is possible hyperkalemia, which could occur with continued potassium administration and a decrease in urinary output since potassium is excreted via the kidneys. Successful management of acute hyperkalemia involves protecting the heart from arrhythmias with the administration of calcium, shifting potassium (K+) into the cells, and enhancing the elimination of K+ from the body.
A 23-year-old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms?
Correct Answer: B. Pulmonary embolism due to deep vein thrombosis (DVT).
In a hospitalized patient on prolonged bed rest, the most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs. These clots can then break loose and travel to the lungs.
A clinic nurse interviews a parent who is suspected of abusing her child. Which of the following characteristics is the nurse least likely to find in an abusing parent?
Correct Answer: C. Self-blame for the injury to the child.
The profile of a parent at risk of abusive behavior includes a tendency to blame the child or others for the injury sustained. Abusers typically blame others, especially their partners, for the mistakes in their lives. This is related to hypersensitivity, but they are not necessarily alike. This occurs because most abusive people don’t hold themselves as being accountable for the actions they commit. Instead, they’ll try to shift the blame to the person that they have abused and somehow say they “deserved it” or that they were forced into a corner.
A child has recently been diagnosed with Duchenne muscular dystrophy (DMD). The parents are receiving genetic counseling prior to planning another pregnancy. Which of the following statements includes the most accurate information?
Correct Answer: A. 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.
The recessive Duchenne gene is located on one of the two X chromosomes of a female carrier. If her son receives the X bearing the gene he will be affected. Thus, there is a 50% chance of a son being affected. Daughters are not affected, but 50% are carriers because they inherit one copy of the defective gene from the mother. The other X chromosome comes from the father, who cannot be a carrier.
The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time?
Correct Answer: D. Risk for infection
Membranes ruptured over 24 hours prior to birth greatly increases the risk of infection to both mother and the newborn. Rupture of membranes results from a variety of factors that ultimately lead to accelerated membrane weakening. This is caused by an increase in local cytokines, an imbalance in the interaction between matrix metalloproteinases and tissue inhibitors of matrix metalloproteinases, increased collagenase and protease activity, and other factors that can cause increased intrauterine pressure.
While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse’s first action?
Correct Answer: B. Massage the fundus
The nurse’s first action should be to massage the fundus until it is firm as uterine atony is the primary cause of bleeding in the first hour after delivery. Approximately 3% to 5% of obstetric patients will experience postpartum hemorrhage. Annually, these preventable events are the cause of one-fourth of maternal deaths worldwide and 12% of maternal deaths in the United States.