Question

The nurse caring for a client with systemic lupus erythematosus (SLE) would include which information in teaching about triggers that can result in an exacerbation of the disease?

Answer 1

Correct Answers:

Ultraviolet (UV) light exposure

Rationale :

🌞Exposure to ultraviolet (UV) light is a known environmental trigger that can lead to exacerbations in systemic lupus erythematosus (SLE).

🧴UV radiation stimulates autoimmune activity, increasing the production of autoantibodies and leading to inflammatory responses.

🩺Patients with SLE are advised to avoid direct sun exposure, wear protective clothing, and use broad-spectrum sunscreen regularly.

📖While genetic predisposition and hormonal changes can influence the disease, UV light is a modifiable and preventable risk factor.

📌Core Message

UV light exposure can stimulate immune hyperactivity in SLE, making it a key trigger to avoid in patient education.

Answer 2

Correct Answers:

Bleeding posterior to the nasal packing.

Rationale :

🩸Frequent swallowing following a rhinoplasty may indicate posterior nasal bleeding, which may not be visible due to packing.

👃This type of bleeding is dangerous because it can be concealed and may lead to hypovolemia or aspiration if not addressed promptly.

🚑The nurse should immediately assess for signs of hemorrhage, such as increased heart rate, pallor, or restlessness.

📋Posterior bleeding is a medical emergency that may require intervention such as repacking, cauterization, or surgical control.

📌Core Message

Frequent swallowing post-rhinoplasty is a red flag for posterior nasal bleeding, which requires immediate evaluation.

Answer 3

Correct Answers:

"Chemotherapy affects all rapidly dividing cells."

Rationale :

💊Chemotherapy works by targeting cells that divide rapidly, a key feature of most cancer cells.

🧬This includes disrupting cell mitosis and DNA replication, effectively slowing or halting tumor growth.

😷Because chemotherapy is non-selective, it also impacts normal rapidly dividing cells like those in the GI tract, bone marrow, and hair follicles.

📖This explains common side effects such as nausea, alopecia, and immunosuppression, which patients must be educated to anticipate.

📌Core Message

Chemotherapy targets rapidly dividing cells, affecting both cancer and normal tissues, leading to common side effects like GI upset and hair loss.

Answer 4

Correct Answers:

Check the patency of the NG tube.

Rationale :

🔄A return of nausea and active bowel sounds after NG decompression suggests that the tube may be clogged or kinked.

🧫If the NG tube is not patent, it cannot relieve gastric distention, leading to accumulation of secretions and worsening symptoms.

🩺Before conducting further assessments or interventions, the nurse should ensure the NG tube is functioning properly.

🛠️This simple step can often resolve the issue quickly and prevent complications such as vomiting or aspiration.

📌Core Message

When symptoms recur with NG decompression, the priority is to check for obstruction and ensure tube patency.

Answer 5

Correct Answers:

Melena

Rationale :

💩Melena, or black tarry stools, is a key sign of upper GI bleeding, often resulting from NSAID-induced gastric irritation.

🩸NSAIDs can erode the gastric lining, causing ulceration and potential hemorrhage.

⚠️This is a medical emergency, as continued bleeding can result in anemia, hypotension, or shock.

📞Immediate reporting ensures prompt evaluation and the initiation of protective therapies like proton pump inhibitors or discontinuation of the NSAID.

📌Core Message

Melena indicates serious GI bleeding, which is a life-threatening adverse effect of NSAID therapy that demands immediate attention.

Answer 6

Correct Answers:

"I have learned some relaxation strategies that decrease my stress."

Rationale :

🧘‍♀️Stress is known to stimulate acid production, worsening peptic ulcer disease.

📚The patient's statement shows an understanding of how stress reduction is part of the treatment plan.

❌Stopping medications or choosing antacids without guidance can lead to treatment failure or complications.

💬This answer reflects a positive behavioral change and successful patient education.

📌Core Message

In peptic ulcer management, stress reduction is a vital component alongside medical treatment, and this understanding shows effective teaching.

Answer 7

Correct Answers:

Assist the patient to get out of bed.

Rationale :

🚶‍♂️Assisting with mobility is within the scope of UAP, as it does not involve judgment or assessment.

🧑‍⚕️The nurse must delegate tasks that are routine, predictable, and low risk to the patient's condition.

📋Tasks like teaching breathing techniques or planning activity levels involve critical thinking and remain the nurse's responsibility.

🛏️Delegating basic assistance promotes team efficiency while keeping the nurse focused on skilled tasks.

📌Core Message

Mobility assistance is a basic task that can be safely delegated to UAPs, as it does not require clinical judgment.

Answer 8

Correct Answers:

Albuterol nebulizer

Rationale :

💨Albuterol is a short-acting beta2-agonist used to relieve acute bronchospasm in asthma.

🚑It works quickly by relaxing bronchial smooth muscle, improving airflow in minutes.

🕒Other options like prednisone or fluticasone are anti-inflammatory but have delayed onset and are not appropriate for immediate relief.

🌬️Albuterol is considered the first-line emergency medication for acute asthma attacks.

📌Core Message

Albuterol is the fastest-acting bronchodilator, making it the first-line treatment in asthma-related respiratory distress.

Answer 9

Correct Answers:

Respiratory Acidosis

Rationale :

🫁Depressed ventilation leads to CO₂ retention, which results in respiratory acidosis due to excess carbonic acid.

🧍‍♀️In head trauma, the respiratory center in the brainstem can be compromised, reducing the drive to breathe effectively.

📉This causes hypoventilation, a hallmark feature of respiratory acidosis, especially if the patient is unconscious.

🚨If untreated, CO₂ buildup can lead to confusion, coma, or even cardiac arrest.

📌Core Message

Respiratory acidosis develops when hypoventilation causes CO₂ retention, commonly seen in head injury with impaired breathing.

Answer 10

Correct Answers:

Place the child in a quiet environment.

Rationale :

🤫Children with Kawasaki disease often have heightened irritability, especially during the subacute phase.

🛏️A quiet setting helps reduce stimuli that may aggravate discomfort, allowing for better rest and emotional regulation.

🧴Applying lotion is appropriate later for skin care, but it does not address the immediate behavioral distress.

👪Calming the child is the first priority to support healing and reduce family stress.

📌Core Message

The best first step for an irritable child with Kawasaki disease is to provide a quiet environment to reduce discomfort and stress.

1 :
The nurse caring for a client with systemic lupus erythematosus (SLE) would include which information in teaching about triggers that can result in an exacerbation of the disease?

2 :
A patient, age 23, underwent a rhinoplasty 6 hours ago. After administering his pain medication, the nurse notes that he is swallowing frequently. What is the most likely cause of the swallowing?

3 :
A 58-year-old man is going to have chemotherapy for lung cancer. He asks the nurse how the chemotherapeutic drugs will work. The most accurate explanation the nurse can give is which of the following?

4 :
A patient with a gastric outlet obstruction has been treated with NG decompression. After the first 24 hours, the patient develops nausea and increased upper abdominal bowel sounds. What is the best action by the nurse?

5 :
A client with systemic lupus erythematosus (SLE) is receiving nonsteroidal anti- inflammatory drug (NSAID) therapy. Which side effect of NSAID therapy should the nurse immediately report to the health care provider?

6 :
The nurse determines that teaching for the patient with peptic ulcer disease has been effective when the patient makes which statement?

7 :
The nurse is caring for a patient with COPD. Which intervention could be delegated to unlicensed assistive personnel (UAP)?

8 :
Which medication should the nurse anticipate being used first in the emergency department for relief of severe respiratory distress related to asthma?

10 :
A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?

1 : The nurse caring for a client with systemic lupus erythematosus (SLE) would include which information in teaching about triggers that can result in an exacerbation of the disease?

2 : A patient, age 23, underwent a rhinoplasty 6 hours ago. After administering his pain medication, the nurse notes that he is swallowing frequently. What is the most likely cause of the swallowing?

3 : A 58-year-old man is going to have chemotherapy for lung cancer. He asks the nurse how the chemotherapeutic drugs will work. The most accurate explanation the nurse can give is which of the following?

4 : A patient with a gastric outlet obstruction has been treated with NG decompression. After the first 24 hours, the patient develops nausea and increased upper abdominal bowel sounds. What is the best action by the nurse?

5 : A client with systemic lupus erythematosus (SLE) is receiving nonsteroidal anti- inflammatory drug (NSAID) therapy. Which side effect of NSAID therapy should the nurse immediately report to the health care provider?

6 : The nurse determines that teaching for the patient with peptic ulcer disease has been effective when the patient makes which statement?

7 : The nurse is caring for a patient with COPD. Which intervention could be delegated to unlicensed assistive personnel (UAP)?

8 : Which medication should the nurse anticipate being used first in the emergency department for relief of severe respiratory distress related to asthma?

10 : A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?

1 :
The nurse caring for a client with systemic lupus erythematosus (SLE) would include which information in teaching about triggers that can result in an exacerbation of the disease?

2 :
A patient, age 23, underwent a rhinoplasty 6 hours ago. After administering his pain medication, the nurse notes that he is swallowing frequently. What is the most likely cause of the swallowing?

3 :
A 58-year-old man is going to have chemotherapy for lung cancer. He asks the nurse how the chemotherapeutic drugs will work. The most accurate explanation the nurse can give is which of the following?

4 :
A patient with a gastric outlet obstruction has been treated with NG decompression. After the first 24 hours, the patient develops nausea and increased upper abdominal bowel sounds. What is the best action by the nurse?

5 :
A client with systemic lupus erythematosus (SLE) is receiving nonsteroidal anti- inflammatory drug (NSAID) therapy. Which side effect of NSAID therapy should the nurse immediately report to the health care provider?

6 :
The nurse determines that teaching for the patient with peptic ulcer disease has been effective when the patient makes which statement?

7 :
The nurse is caring for a patient with COPD. Which intervention could be delegated to unlicensed assistive personnel (UAP)?

8 :
Which medication should the nurse anticipate being used first in the emergency department for relief of severe respiratory distress related to asthma?

10 :
A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?