Nokea
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.
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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 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 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.
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.
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.