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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.
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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.
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 4 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
For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client experiencing cardiac tamponade.
- A. Prepare the client for an immediate thoracentesis
- B. Obtain a prescription for an isotonic fluid bolus
- C. Perform frequent vital sign collection
- D. Obtain a prescription for intravenous furosemide
Correct Answer: C
Rationale: For cardiac tamponade, frequent vital sign collection (C) is indicated to monitor hemodynamic stability. Thoracentesis (A) is for pleural effusion, not pericardial fluid. Fluid bolus (B) may worsen tamponade by increasing pericardial pressure. Furosemide (D) is contraindicated as it reduces preload, which is already compromised.
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 5 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 prepares the client for an emergent pericardiocentesis and it is essential to have …………….. at the bedside. During the procedure, it is a priority for the nurse to monitor the client's ………….
- A. a bottle of sterile water
- B. a defibrillator
- C. positive pressure ventilation
- D. urinary output
- E. cardiac rhythm
- F. Gasaow coma scale
Correct Answer: B,E
Rationale: A defibrillator (B) is essential at the bedside during pericardiocentesis due to the risk of arrhythmias from needle insertion. Monitoring cardiac rhythm (E) is a priority to detect complications like ventricular arrhythmias. Sterile water (A), positive pressure ventilation (C), urinary output (D), and Glasgow Coma Scale (F) are not directly relevant.
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 nurse in the outpatient clinic is assessing a client with systemic lupus erythematosus (SLE). Which laboratory data is essential for the nurse to monitor to determine if the client is experiencing a complication?
- A. urine analysis
- B. hemoglobin A1C (HbA1C)
- C. thyroid-stimulating hormone (TSH)
- D. ammonia
Correct Answer: A
Rationale: Urine analysis is essential for monitoring complications in SLE, as it can detect proteinuria or hematuria, which are indicative of lupus nephritis, a common and serious complication. HbA1C is related to diabetes management, TSH to thyroid function, and ammonia to liver function, none of which are primary concerns for SLE complications.