Nokea
The nurse is assessing a client who has Raynaud's phenomenon. Which of the following would be an expected finding?
- A. Digit color changes
- B. Flapping hand tremor
- C. Painless skin ulcers
- D. Janeway lesions
Correct Answer: A
Rationale: Raynaud's phenomenon is characterized by digit color changes (white, blue, red) due to vasospasms triggered by cold or stress. Flapping hand tremors are associated with liver disease, painless skin ulcers with venous insufficiency, and Janeway lesions with endocarditis, none of which are typical of Raynaud's.
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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 3 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 client is most likely experiencing ………………..
- A. acute coronary syndrome
- B. pneumothorax
- C. cardiac tamponade
Correct Answer: C
Rationale: Given the client's SLE history, chest pain, and lack of ST-elevations or troponin elevation, cardiac tamponade is the most likely diagnosis, as SLE can cause pericarditis leading to fluid accumulation. Acute coronary syndrome is less likely without ECG or troponin changes, and pneumothorax is not supported by the scenario.
The nurse is assessing a client who has suspected Raynaud phenomenon/disease. Which of the following findings would support a diagnosis of Raynaud phenomenon/disease?
- A. unilateral swelling of the leg
- B. painful vasospasms
- C. crepitus of the joints
- D. claudication in feet and lower extremities
Correct Answer: B
Rationale: Painful vasospasms (B) are a hallmark of Raynaud's phenomenon, caused by cold or stress-induced vasoconstriction. Unilateral leg swelling (A) suggests venous issues, crepitus (C) indicates joint pathology, and claudication (D) is related to peripheral artery disease.
The nurse is caring for a client with Guillain-Barré syndrome (GBS). The nurse plans on taking which priority action?
- A. Assessing respiratory status frequently.
- B. Administering intravenous immunoglobulin (IVIG) as prescribed.
- C. Providing passive range of motion exercises to maintain joint mobility.
- D. Monitoring for autonomic dysreflexia.
Correct Answer: A
Rationale: Frequent respiratory status assessment (A) is the priority in GBS due to the risk of respiratory muscle paralysis. IVIG (B) is a treatment, not a nursing action priority. Range of motion exercises (C) and autonomic dysreflexia monitoring (D) are secondary concerns.
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 nurse is planning a staff development conference about anaphylaxis. Which of the following information should the nurse include?
- A. 0.9% saline should be infused once vascular access is established.
- B. The initial treatment is intravenous diphenhydramine.
- C. The client should carry a prefilled syringe of hydrocortisone.
- D. If shock occurs, the client should be positioned in reverse Trendelenburg.
Correct Answer: A
Rationale: 0.9% saline infusion (A) is critical in anaphylaxis to restore volume in shock. Epinephrine, not diphenhydramine (B), is the initial treatment. Clients carry epinephrine (not hydrocortisone, C) in auto-injectors. Reverse Trendelenburg (D) is incorrect; flat or leg-elevated positioning is preferred.