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The nurse practitioner assesses a client in the physician’s office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)?
- A. Facial erythema, profuse proteinuria, pleuritis, fever, and weight loss
- B. Pericarditis, photosensitivity, polyarthralgia, and painful mucous membrane ulcers
- C. Weight gain, hypervigilance, hypothermia, and edema of the legs
- D. Hypothermia, weight gain, lethargy, and edema of the arms
Correct Answer: B
Rationale: The correct answer is B because the assessment findings of pericarditis, photosensitivity, polyarthralgia, and painful mucous membrane ulcers are classic manifestations of systemic lupus erythematosus (SLE). Pericarditis can present as chest pain aggravated by deep breathing or lying flat, photosensitivity refers to skin rashes triggered by sunlight exposure, polyarthralgia involves joint pain in multiple joints, and painful mucous membrane ulcers are common in the mouth or nose. These findings align with the diagnostic criteria for SLE.
Choices A, C, and D are incorrect because they do not align with the typical presentation of SLE. Choice A includes facial erythema which is a common symptom, but the presence of profuse proteinuria, pleuritis, fever, and weight loss are not specific to SLE. Choices C and D include symptoms like weight gain, hypothermia, and edema which are not characteristic of SLE.
In summary
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When teaching a client about insulin administration, the nurse should include which instruction?
- A. “Administer insulin after the first meal of the day.”
- B. “Inject insulin at a 45-degree angle into the deltoid muscle.”
- C. “Shake the insulin vial vigorously before withdrawing the medication.”
- D. “Draw up clear insulin first when mixing two types of insulin in one syringe.”
Correct Answer: D
Rationale: The correct answer is D because drawing up clear insulin first when mixing two types of insulin in one syringe prevents contamination. Clear insulin is drawn up first to avoid clouding from the cloudy insulin. This ensures accurate dosing and prevents potential medication errors.
A: Incorrect. Administering insulin after the first meal may lead to hypoglycemia if the client skips or delays meals.
B: Incorrect. Insulin should not be injected into the deltoid muscle as it can lead to inconsistent absorption rates.
C: Incorrect. Vigorously shaking the insulin vial can cause bubbles, affecting the accuracy of the dose and potentially altering its effectiveness.
A patient had a lumbar injury. Which neurological test by the nurse would be affected?
- A. Rhine’s test
- B. Pupillary reaction
- C. Romberg’s test
- D. Patellar reflex
Correct Answer: C
Rationale: The correct answer is C: Romberg’s test. Romberg’s test assesses a patient's ability to maintain balance with eyes closed, relying on proprioception from the lower limbs. A lumbar injury can affect proprioception, leading to impaired balance. Rhine’s test evaluates auditory function, not affected by a lumbar injury. Pupillary reaction assesses cranial nerve function, unrelated to a lumbar injury. The patellar reflex is a deep tendon reflex, primarily involving the spinal cord segments L2-L4, not directly affected by a lumbar injury.
After assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen for the patient’s headache. Which action by the nurse is priority for this patient?
- A. Eliminate headache from the nursing care plan.
- B. Direct the nursing assistive personnel to ask if the headache is relieved.
- C. Reassess the patient’s pain level in 30 minutes.
- D. Revise the plan of care.
Correct Answer: C
Rationale: The correct answer is C: Reassess the patient's pain level in 30 minutes. This is the priority action as it allows the nurse to evaluate the effectiveness of the acetaminophen in relieving the patient's headache. By reassessing the pain level, the nurse can determine if the medication is working or if further intervention is needed.
A: Eliminating the headache from the care plan is not appropriate as the patient's comfort and pain relief should be a priority.
B: Directing the nursing assistive personnel to inquire if the headache is relieved is not thorough assessment and does not provide direct evaluation of the patient's pain level.
D: Revising the plan of care may be necessary based on the reassessment, but it is not the immediate priority compared to evaluating the patient's response to treatment.
The nurse is reviewing a patient’s database for significant changes and discovers that the patient has not voided in over 8 hours. The patient’s kidney function lab results are abnormal, and the patient’s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?
- A. Diagnosis
- B. Planning NursingStoreRN
- C. Implementation
- D. Evaluation
Correct Answer: A
Rationale: The correct answer is A: Diagnosis. After reviewing the patient's database and identifying concerning signs such as not voiding for over 8 hours, abnormal kidney function, and decreased oral intake, the nurse must move to the diagnosis step. In this step, the nurse will analyze the data collected to identify the patient's actual and potential health problems. This will help the nurse formulate appropriate nursing diagnoses and develop a plan of care to address the identified issues.
Choice B (Planning) comes after the diagnosis step, where specific goals and interventions are established; Choice C (Implementation) follows planning and involves executing the planned interventions; Choice D (Evaluation) is the final step where the nurse assesses the effectiveness of the interventions. In this scenario, the nurse must first determine the patient's health problems before proceeding to planning, implementing, and evaluating care.
A client has an abnormal result on a Papanicolaou test. After admitting that she read her chart while the nurse was out of the room, the client asks what dysplasia means. Which definition should the nurse provide?
- A. Presence of completely undifferentiated tumor cells that don’t resemble cells of the tissues of their origin
- B. Increase in the number of normal cells in a normal arrangement in a tissue or an organ
- C. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn’t found
- D. Alteration in the size, shape, and organization of differentiated cells
Correct Answer: D
Rationale: The correct answer is D because dysplasia refers to the alteration in the size, shape, and organization of differentiated cells. Dysplasia is an abnormal growth or development of cells that can be a precursor to cancer. It is characterized by changes in cell size, shape, and organization, which can be seen in Papanicolaou tests.
Choice A is incorrect because it describes an undifferentiated tumor, not dysplasia. Choice B is incorrect as it describes hyperplasia, not dysplasia. Choice C is incorrect as it refers to metaplasia, not dysplasia.
In summary, dysplasia is specifically about the abnormal changes in the appearance and organization of differentiated cells, making choice D the correct definition.