1 :

Hint : πŸ’‰A compromised immune system increases risk even from common organisms.

Correct Answers:

  • "It is very easy to get infections as HIV suppresses the immune system."


Rationale :

🦠HIV targets and destroys CD4+ T cells, which are essential for immune system function.

🧬The resulting immunosuppression makes the client vulnerable to opportunistic infections.

πŸ›‘οΈAntiviral therapy helps control viral replication but doesn't eliminate immune suppression entirely.

πŸ“‰While antiretroviral therapy improves prognosis, the immune system remains at risk without adherence.

πŸ“ŒCore Message

HIV weakens the immune system by destroying CD4+ cells, increasing the client’s vulnerability to infections.

2 :

0700:

Assisted client with getting dressed, provided morning cup of herbal tea. Client stated they did not sleep well and feel tired this morning, Standby assist when walking to the dining hall.

0730:

Client ate 75% of breakfast: scrambled eggs, wheat toast, 2 slices bacon, glass of whole milk.

0815:

Client requested a short nap, accompanied back to bed.

0930:

Feeling well-rested, client participated in armchair exercise class, stayed to chat with residents then assisted to back patio for cigarette use.

1130:

Client ate 100% of lunch, roasted chicken, green beans, watermelon, glass of water.

1300:

Attended group outing to local high school's music concert, ate snack of apple juice and crackers.

1700:

Client ate 75% of dinner pork chops, cauliflower, couscous, glass of water.

1900:

Client reports pressure in chest along with "burning sensation with frequent belching.

1915:

Administered PRN calcium carbonate.


Which information documented in the client's activity log does the nurse identify that may have led to a flare-up of GER symptoms? Select all that apply.


Answer Options

Hint : πŸ₯“High-fat meals and nicotine both affect LES tone and digestion.

Correct Answers:

  • Nicotine use
  • Breakfast intake


Rationale :

🍽️High-fat foods like bacon can delay gastric emptying and trigger GERD symptoms.

🚬Nicotine lowers lower esophageal sphincter (LES) tone, leading to acid reflux.

πŸ›οΈAlthough rest is necessary, timing of meals and reflux triggers are more influential in GERD.

πŸ“„The charted breakfast and smoking event are both classic risk factors for reflux flare-ups.

πŸ“ŒCore Message

Nicotine use and high-fat foods like bacon are known triggers that aggravate GERD symptoms in affected clients.

3 :

Hint : πŸ•ΊMotor control depends on adequate dopamine in the brain.

Correct Answers:

  • Risk for falls because of dopamine imbalance.


Rationale :

🧠Parkinson’s disease is caused by a dopamine deficiency in the substantia nigra.

🦴This deficiency leads to motor symptoms like tremors, rigidity, and postural instability, increasing fall risk.

πŸ”¬Dopamine plays a central role in voluntary muscle control, and its imbalance is key in Parkinson’s.

⚠️Fall risk is the most relevant nursing concern for newly diagnosed Parkinson’s clients.

πŸ“ŒCore Message

Dopamine imbalance causes movement issues in Parkinson's disease, significantly raising the client’s risk for falls.

4 :

Hint : 🧽Early skin washing helps limit contact spread and damage.

Correct Answers:

  • Wash the affected area.


Rationale :

🧴Immediate decontamination prevents spread of urushiol oil, the irritant in poison ivy.

🚿Washing the skin reduces severity of dermatitis and future inflammation.

🩹Delaying cleansing allows the allergen to bind and worsen the immune response.

🌿Topical corticosteroids are helpful later but not as effective as first-line decontamination.

πŸ“ŒCore Message

The nurse must first wash the skin to reduce urushiol exposure, which is the cause of poison ivy contact dermatitis.

5 :

Hint : 🌞No sweating with high temp suggests thermoregulatory failure.

Correct Answers:

  • Heatstroke


Rationale :

🌑️Heatstroke presents with hot, dry skin, confusion, and elevated heart rate.

🧠This is a medical emergency due to potential organ damage from prolonged hyperthermia.

πŸ’β€β™‚οΈLack of sweating indicates failure of normal thermoregulatory mechanisms.

πŸš‘Confusion and high temperature further confirm central nervous system dysfunction in heatstroke.

πŸ“ŒCore Message

Heatstroke presents with confusion, tachycardia, and absence of sweating, signaling a breakdown in temperature regulation.

6 :

Hint : 🚽Frequent vomiting removes acid, shifting pH to alkaline state.

Correct Answers:

  • Metabolic alkalosis


Rationale :

🀒Prolonged vomiting leads to loss of gastric hydrochloric acid, raising blood bicarbonate levels.

πŸ’‰This results in metabolic alkalosis, a condition with increased blood pH.

πŸ§ͺThe body compensates with hypoventilation, but this response is limited.

πŸ₯ΌNurses must monitor for electrolyte imbalances, especially potassium, which often drops in alkalosis.

πŸ“ŒCore Message

Extended vomiting causes hydrogen ion loss, resulting in metabolic alkalosis, which requires prompt correction.

7 :

Hint : 🦴No muscle use over time leads to shrinkage and weakness.

Correct Answers:

  • Disuse atrophy


Rationale :

πŸ›ŒExtended immobility leads to muscle wasting due to lack of stimulation.

πŸ’ͺThis is classified as disuse atrophy, where muscle mass reduces from inactivity, not disease.

πŸ”¬The cells shrink in size, reflecting a reduction in functional demand.

πŸ“‰It is a reversible condition with gradual reconditioning and physical therapy.

πŸ“ŒCore Message

Lack of movement over an extended period results in disuse atrophy, marked by reduced muscle size and strength.

8 :

Hint : 🚷An open chest wound risks lung collapse if not sealed quickly.

Correct Answers:

  • Cover the open area with an airtight bandage.


Rationale :

🩹Open chest wounds can lead to a sucking chest wound and tension pneumothorax.

πŸš‘Priority is to seal the wound with an occlusive dressing to prevent air entry into the pleural space.

πŸ›‘Immediate closure stabilizes intrapleural pressure and improves respiratory function.

πŸ’¨Other actions, like oxygen or imaging, are secondary once the wound is sealed.

πŸ“ŒCore Message

The nurse must seal the open chest wound with an airtight dressing to prevent air entry and lung collapse.

9 :

Hint : 🧫RBCs change shape in this genetic disorder, causing poor oxygenation.

Correct Answers:

  • Sickle cell anemia


Rationale :

🧬Sickle cell anemia is a genetic disorder where RBCs become abnormally shaped under stress.

πŸ“‰These misshapen cells impair oxygen delivery and can clog vessels, leading to pain and organ damage.

🩸The defect lies in the hemoglobin, specifically HbS, which polymerizes under low oxygen.

πŸ‘¨β€πŸ‘©β€πŸ‘§This condition is inherited, and client education should cover genetic counseling and crisis prevention.

πŸ“ŒCore Message

Sickle cell anemia is a hereditary disorder where abnormal RBCs impair oxygen transport, leading to systemic complications.

10 :

Hint : πŸ§ͺHormone levels are kept stable using reverse signaling.

Correct Answers:

  • Negative feedback


Rationale :

πŸ”The thyroid gland is regulated by a negative feedback loop involving TSH and T3/T4.

πŸ’β€β™‚οΈWhen thyroid hormone levels rise, the pituitary gland reduces TSH secretion.

🧠This feedback mechanism maintains homeostasis in endocrine function.

πŸ‘©πŸ»β€πŸ€β€πŸ§‘πŸΏClient education should include understanding how hormonal balance is self-regulated through feedback.

πŸ“ŒCore Message

The thyroid gland uses a negative feedback mechanism to regulate hormone secretion and maintain hormonal balance.

Total Questions: 10

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