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A client in the medical ward developed sudden hypotension, difficulty breathing, and cyanosis shortly after receiving an intravenous penicillin infusion. Based on the nurses' understanding of anaphylactic reactions, what can the nurse conclude is the cause of this reaction?
- A. Potent antibodies formed when the antibiotic was infused into the client during this infusion.
- B. The client was previously exposed to penicillin, enabling their body to produce antibodies.
- C. The client developed passive immunity to penicillin.
- D. Atopic sensitization occurred.
Correct Answer: B
Rationale: Anaphylaxis occurs due to prior exposure to penicillin (B), leading to IgE antibody production and a rapid allergic response upon re-exposure. Antibodies don't form instantly during infusion (A), passive immunity (C) involves transferred antibodies, and atopic sensitization (D) is a predisposition, not the direct cause.
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You are caring for a patient with Raynaud's disease who has intractable pain. The patient is scheduled to undergo surgical interruption of pain conduction pathways to improve vascular blood supply as well as eliminate vasospasm and pain. Which type of surgery is the patient most likely to undergo?
- A. Cordotomy
- B. Rhizotomy
- C. Neurectomy
- D. Sympathectomy
Correct Answer: D
Rationale: Sympathectomy (D) interrupts sympathetic nerve pathways to reduce vasospasm and improve blood flow in Raynaud's disease. Cordotomy (A) and rhizotomy (B) target pain pathways for other conditions, and neurectomy (C) involves peripheral nerve removal, less specific for Raynaud's.
The following scenario applies to the next 6 items
The nurse in the intensive care unit (ICU) is caring for a 59-year-old female client
Item 1 of 6
Admission Note
Nurses' Notes
Physician Orders
1450 - Client was admitted directly from the primary health care physician's office for a severe exacerbation of systemic lupus erythematosus (SLE). The client was being treated outpatient with corticosteroids but was not responding. Reported intermittent chest pain at the physician's office and became pale and
Diaphoretic. The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
• The client was directly admitted to the intensive care unit for observation and medical management. • Cardiac consultation has been placed, and laboratory work is pending. The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension
Which of the following assessment findings require immediate follow-up? Select all that apply.
- A. lung sounds
- B. cardiac sounds
- C. temperature
- D. blood pressure
- E. butterfly-shaped rash on face
- F. pulse oximetry
- G. pulse
Correct Answer: A,B,D,F,G
Rationale: Given the client's severe SLE exacerbation, chest pain, pallor, and diaphoresis, immediate follow-up is needed for lung sounds (A) to assess for pulmonary issues like pleural effusion, cardiac sounds (B) for pericarditis or tamponade, blood pressure (D) for hemodynamic stability, pulse oximetry (F) for oxygenation, and pulse (G) for cardiovascular status. Temperature (C) and butterfly rash (E) are less urgent in this acute context.
The following scenario applies to the next 6 items
The nurse in the intensive care unit (ICU) is caring for a 59-year-old female client
Item 6 of 6
Admission Note
Nurses' Notes
Physician Orders
1450 - Client was admitted directly from the primary health care physician's office for a severe exacerbation of systemic lupus erythematosus (SLE). The client was being treated outpatient with corticosteroids but was not responding. Reported intermittent chest pain at the physician's office and became pale and
Diaphoretic. The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
• The client was directly admitted to the intensive care unit for observation and medical management. • Cardiac consultation has been placed, and laboratory work is pending. The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension
The nurse teaches the client self-care practices for systemic lupus erythematosus (SLE). Which two (2) client statements indicate effective understanding?
- A. I should limit my exposure to direct sunlight to 45 continuous minutes each day.
- B. I should wear long sleeves and a large-brimmed hat when outdoors.
- C. I should wash my skin with an antibacterial soap.
- D. Cosmetics must be selected carefully and should include moisturizers and sun protectors.
- E. I should refrain from receiving any vaccine.
Correct Answer: B,D
Rationale: Wearing long sleeves and a large-brimmed hat (B) and using cosmetics with moisturizers and sun protectors (D) indicate understanding of photoprotection, crucial for SLE to prevent rash exacerbation. Limiting sun exposure to 45 minutes (A) is too specific and risky, antibacterial soap (C) is unnecessary, and avoiding all vaccines (E) is incorrect as some are safe.
The nurse in the emergency department (ED) is assessing a client with anaphylactic shock. Which of the following findings would support a diagnosis of anaphylactic shock?
- A. hypertension
- B. crackles (rales) in the lung fields
- C. cutaneous cyanosis
- D. pruritus
Correct Answer: C,D
Rationale: Anaphylactic shock is characterized by cutaneous cyanosis (C) from poor perfusion and pruritus (D) from histamine release. Hypertension (A) is not typical, as hypotension is expected. Crackles (B) suggest pulmonary edema, not a primary feature of anaphylaxis.
The nurse is discussing the underlying mechanism of psoriasis with a client recently diagnosed with the condition. The nurse explains that psoriasis is primarily associated with?
- A. overactivity of the immune system targeting healthy skin cells.
- B. deficiency of T lymphocytes leading to skin inflammation.
- C. impaired production of melanocytes causing skin discoloration.
- D. excessive sebum production resulting in follicular plugging.
Correct Answer: A
Rationale: Psoriasis is caused by overactivity of the immune system, particularly T cells, attacking healthy skin cells (A), leading to rapid skin turnover and plaques. T lymphocyte deficiency (B) is unrelated, melanocyte issues (C) cause pigmentation changes, and excessive sebum (D) is linked to acne.