Which of the following antibodies has least association with neonatal lupus?
- A. Anti-Ro (SSA)
- B. Anti-La (SSB)
- C. Anti-RNP
- D. Anti-CCP
Correct Answer: D
Rationale: Anti-CCP antibodies have the least association with neonatal lupus compared to the other antibodies listed.
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The nurse is caring for a child with a diagnosis of Kawasaki disease. The child’s parent asks the nurse, “How does Kawasaki disease affect my child’s heart and blood vessels?†On what understanding is the nurse’s response based?
- A. Inflammation weakens blood vessels, leading to aneurysm.
- B. Increased lipid levels lead to the development of atherosclerosis.
- C. Untreated disease causes mitral valve stenosis.
- D. Altered blood flow increases cardiac workload with resulting heart failure.
Correct Answer: A
Rationale: Inflammation of vessels weakens the walls of the vessels and often results in aneurysm.
A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions?
- A. Prepare for transcutaneous pacing
- B. Deliver another defibrillator shock
- C. Administer IV Epinephrine per ACLS protocol
- D. Give IV dose of adenosine rapidly over 1-2 seconds
Correct Answer: D
Rationale: The client may experience arrhythmia, and the correct intervention is giving IV adenosine to slow the heart rate.
Three days after a female client with multiple sclerosis (MS) is admitted to the hospital with a severe urinary tract infection, she reports experiencing double vision. Which intervention should the nurse implement?
- A. Patch one eye and then the other every few hours
- B. Encourage bedrest until the diplopia is resolved
- C. Instruct the client to limit intake of oral fluids
- D. Administer artificial tear drops to both eyes
Correct Answer: A
Rationale: Patching each eye helps alleviate double vision caused by MS-related vision impairment.
Which clinical manifestation is included in toxic shock syndrome?
- A. Severe hypertension
- B. Subnormal temperature
- C. Erythematous macular rash
- D. Papular rash over extremities
Correct Answer: C
Rationale: One of the diagnostic criteria for toxic shock syndrome is a diffuse macular erythroderma. Hypotension is one of the manifestations. Fever of 38.9° C or higher is a characteristic. Desquamation of the palms and soles of the feet occurs in about 1 to 2 weeks.
A client with Guillain-Barre syndrome has paralysis of all extremities and requires mechanical ventilation. The nurse observes that the client is not blinking. Which action should the nurse implement?
- A. Protect cornea with lubricant and eye shields
- B. Administer artificial tears every hour.
- C. Encourage the client to blink every 10 minutes.
- D. Keep the client's eyes closed with adhesive tape.
Correct Answer: A
Rationale: Lack of blinking increases the risk of corneal damage. Lubricants and eye shields prevent dryness and injury to the cornea.
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