Question

An adult client is diagnosed with gastroesophageal reflux disease (GERD). Click to identify a possible cause for the GERD. Select one option.

Answer 1

Correct Answers:

History of a hiatal hernia

Rationale :

💁‍♂️A hiatal hernia allows part of the stomach to move through the diaphragm into the chest cavity.

🔥This anatomical change weakens the lower esophageal sphincter, allowing gastric contents to reflux into the esophagus.

🧪Repeated exposure to gastric acid produces heartburn, regurgitation, and irritation associated with gastroesophageal reflux disease.

🛏️Elevating the head of the bed and avoiding smoking are protective measures, rather than causes of reflux.

📌Core Message

A hiatal hernia can weaken the lower esophageal barrier and promote acid reflux into the esophagus.

Answer 2

Correct Answers:

"There is uncontrolled growth of cancer cells in the bone marrow."

Rationale :

🧬Leukemia involves uncontrolled production of abnormal white blood cells within the bone marrow.

🦴The abnormal cells multiply rapidly and crowd out normal marrow cells responsible for producing healthy blood components.

🩸Reduced production of normal red blood cells, platelets, and functional leukocytes can cause anemia, bleeding, and infection.

🌐The malignant cells can enter the bloodstream and spread to other organs, so the disease is not limited to the marrow.

📌Core Message

Leukemia is the uncontrolled growth of abnormal blood-forming cells in the bone marrow, which suppresses normal blood-cell production.

Answer 3

Correct Answers:

"For vitamin A, I will include more skim milk and egg whites into my diet."

Rationale :

🥚Egg whites contain little to no vitamin A because most of the vitamin is concentrated in the egg yolk.

🥛Some skim milk is fortified with vitamin A, but relying on egg whites does not provide an adequate dietary source.

🥕Good sources include orange or dark-green vegetables, liver, fortified dairy products, and egg yolks.

🧈Because vitamin A is a fat-soluble vitamin, it is absorbed with dietary fat and stored in body tissues.

📌Core Message

Egg yolks, fortified milk, liver, and colorful vegetables provide vitamin A, while egg whites are not a significant source.

Answer 4

Correct Answers:

Cerebellum

Rationale :

⚖️The cerebellum coordinates balance, posture, muscle tone, and smooth voluntary movement.

🚶Damage to this structure can cause unsteady gait, poor coordination, and difficulty maintaining an upright position.

🎯The cerebellum receives sensory information about body position and helps adjust movement precisely.

🧠Difficulty with both balance and posture strongly indicates impaired cerebellar function.

📌Core Message

The cerebellum maintains balance, posture, coordination, and smooth voluntary movement.

Answer 5

Correct Answers:

"There is no movement or peristalsis in your intestines."

Rationale :

🛑A paralytic ileus occurs when intestinal peristalsis temporarily stops without a physical blockage.

🏥It commonly develops after abdominal surgery because anesthesia, bowel manipulation, and certain medications reduce intestinal motility.

🎈The client may develop abdominal distention, absent bowel sounds, nausea, and inability to pass stool or flatus.

⏳Normal bowel function usually returns gradually as peristaltic activity resumes.

📌Core Message

A paralytic ileus is the temporary absence of intestinal peristalsis, commonly occurring after abdominal surgery.

Answer 6

Correct Answers:

The client is unable to identify a paperclip by touch.

Rationale :

✋The parietal lobe interprets sensory information such as touch, pressure, temperature, and body position.

📎The inability to identify a familiar object by touch is known as astereognosis.

🧠Astereognosis commonly results from dysfunction of the contralateral parietal cortex despite intact primary sensation.

🔍Testing object recognition by touch evaluates higher-level cortical sensory processing.

📌Core Message

A parietal-lobe lesion can cause astereognosis, which is the inability to identify a familiar object through touch.

Answer 7

Correct Answers:

Cover the open area with an airtight bandage.

Rationale :

👉An open chest wound allows air to enter the pleural cavity and can produce an open pneumothorax.

🩹Applying an occlusive dressing immediately limits additional air entry through the wound.

🚨The dressing is commonly secured on three sides so trapped air can escape while outside air is prevented from entering.

❤️Closing the wound improves ventilation and supports stabilization before diagnostic tests or chest-tube placement.

📌Core Message

An open chest wound requires immediate application of an occlusive dressing to prevent worsening pneumothorax and respiratory compromise.

Answer 8

Correct Answers

"I will contact the health care provider to speak with you." [ Not Appropriate ]
"Growth of a hemangioma is expected during infancy." [ Appropriate ]
"It can take several years to resolve fully." [ Appropriate ]
"There are some medication options that can help." [ Appropriate ]
"A specialist will evaluate it if the growth does not stop soon." [ Appropriate ]
"We will need to do a biopsy of the lesion." [ Not Appropriate ]

Rationale :

🍓An infantile hemangioma commonly grows rapidly during infancy before gradually beginning to involute.

📆Complete resolution can take several years because the lesion shrinks slowly over time.

💊Medication such as propranolol may be prescribed when a hemangioma threatens function, ulcerates, or continues growing significantly.

👩‍⚕️Specialist evaluation is appropriate when the lesion grows rapidly, affects vital structures, or fails to follow the expected pattern.

🔬A biopsy is usually unnecessary when the lesion’s appearance and progression are typical of a hemangioma.

📌Core Message

Infantile hemangiomas often enlarge during infancy, gradually resolve over several years, and may require medication or specialist evaluation when growth causes complications.

Answer 9

Correct Answers:

The HPV vaccine can reduce the risk for cervical cancer.
HPV infection is associated with cervical cancer risk.

Rationale :

🦠Certain high-risk types of human papillomavirus can cause persistent infection and cellular changes in the cervix.

🎗️Persistent infection with oncogenic HPV strains is a major risk factor for cervical cancer.

💉The HPV vaccine protects against several high-risk strains and substantially reduces the risk of precancerous cervical lesions.

🛡️Vaccination can still provide protection after exposure because the teen might not have encountered every vaccine-covered HPV strain.

📌Core Message

HPV infection increases cervical cancer risk, while HPV vaccination reduces the risk by protecting against common high-risk viral strains.

Answer 10

Correct Answers:

Sickle cell anemia

Rationale :

🧬Sickle cell anemia is an inherited hemoglobinopathy involving abnormal synthesis of hemoglobin S.

🩸The abnormal hemoglobin causes red blood cells to become rigid, fragile, and sickle-shaped during reduced oxygen states.

🔬These abnormal cells undergo premature destruction, producing chronic hemolytic anemia.

👨‍👩‍👧Because the condition is genetically inherited, education should include triggers, complications, hydration, and family screening.

📌Core Message

Sickle cell anemia is an inherited disorder characterized by abnormal hemoglobin S and distorted red blood cells.

Date	Findings
1/29	1 cm ecchymosis on the left side of the neck.
4/8	3 cm reddened area with irregular borders on the left side of the neck.
7/13	5 cm deep red area with irregular borders on the left side of the neck.
10/10	8 cm lesion on the left side of the neck; deep red, raised, and spongy.

Potential Nursing Response	Appropriate	Not Appropriate
"I will contact the health care provider to speak with you."
"Growth of a hemangioma is expected during infancy."
"It can take several years to resolve fully."
"There are some medication options that can help."
"A specialist will evaluate it if the growth does not stop soon."
"We will need to do a biopsy of the lesion."

1 :
An adult client is diagnosed with gastroesophageal reflux disease (GERD). Click to identify a possible cause for the GERD. Select one option.

2 :
A client in the oncologist's office has leukemia. As the client and family are leaving the office, the parent says to the nurse, "I didn't quite get it when the doctor explained it. What exactly is happening in my son's body with this leukemia?" What is an appropriate response by the nurse?

3 :
The nurse teaches a client about increasing vitamin A intake. Which statement by the client requires further action?

4 :
A client is having difficulty maintaining balance and posture. Based on the functional areas of the brain, which structure should the nurse identify as being involved in the client's condition?

5 :
A client is 24 hours postoperative, and the nurse determines that the client is experiencing paralytic ileus. How does the nurse explain this to the client?

6 :
The nurse cares for a client newly diagnosed with a tumor in the parietal lobe. Which finding should the nurse anticipate?

7 :
A client arrives at the emergency department with an open chest wound from a knife stabbing. What is the nurse's priority action?

8 :
Review the electronic health record.

Correct Answers

9 :
A teenager visits the school nurse concerned with recent exposure to the human papillomavirus (HPV). What should the nurse include when speaking with the teen? Select all that apply.

10 :
A young client has a genetic disorder of the red blood cells (RBC), where the RBCs and hemoglobin synthesis are abnormal. Based on this information, which type of anemia will the nurse educate the client and parents about?

📌Core Message

1 : An adult client is diagnosed with gastroesophageal reflux disease (GERD). Click to identify a possible cause for the GERD. Select one option.

2 : A client in the oncologist's office has leukemia. As the client and family are leaving the office, the parent says to the nurse, "I didn't quite get it when the doctor explained it. What exactly is happening in my son's body with this leukemia?" What is an appropriate response by the nurse?

3 : The nurse teaches a client about increasing vitamin A intake. Which statement by the client requires further action?

4 : A client is having difficulty maintaining balance and posture. Based on the functional areas of the brain, which structure should the nurse identify as being involved in the client's condition?

5 : A client is 24 hours postoperative, and the nurse determines that the client is experiencing paralytic ileus. How does the nurse explain this to the client?

6 : The nurse cares for a client newly diagnosed with a tumor in the parietal lobe. Which finding should the nurse anticipate?

7 : A client arrives at the emergency department with an open chest wound from a knife stabbing. What is the nurse's priority action?

8 : Review the electronic health record.

Correct Answers

9 : A teenager visits the school nurse concerned with recent exposure to the human papillomavirus (HPV). What should the nurse include when speaking with the teen? Select all that apply.

10 : A young client has a genetic disorder of the red blood cells (RBC), where the RBCs and hemoglobin synthesis are abnormal. Based on this information, which type of anemia will the nurse educate the client and parents about?

📌Core Message

1 :
An adult client is diagnosed with gastroesophageal reflux disease (GERD). Click to identify a possible cause for the GERD. Select one option.

2 :
A client in the oncologist's office has leukemia. As the client and family are leaving the office, the parent says to the nurse, "I didn't quite get it when the doctor explained it. What exactly is happening in my son's body with this leukemia?" What is an appropriate response by the nurse?

3 :
The nurse teaches a client about increasing vitamin A intake. Which statement by the client requires further action?

4 :
A client is having difficulty maintaining balance and posture. Based on the functional areas of the brain, which structure should the nurse identify as being involved in the client's condition?

5 :
A client is 24 hours postoperative, and the nurse determines that the client is experiencing paralytic ileus. How does the nurse explain this to the client?

6 :
The nurse cares for a client newly diagnosed with a tumor in the parietal lobe. Which finding should the nurse anticipate?

7 :
A client arrives at the emergency department with an open chest wound from a knife stabbing. What is the nurse's priority action?

8 :
Review the electronic health record.

9 :
A teenager visits the school nurse concerned with recent exposure to the human papillomavirus (HPV). What should the nurse include when speaking with the teen? Select all that apply.

10 :
A young client has a genetic disorder of the red blood cells (RBC), where the RBCs and hemoglobin synthesis are abnormal. Based on this information, which type of anemia will the nurse educate the client and parents about?