EAQ 2

A student nurse is teaching a client about preventive measures for Lyme disease. Which instruction given by the student nurse indicates a need for correction? a. Wear dark colored dresses b. Wear closed shoes or boots. c. Tuck your shirt into your pants. d. Bathe immediately after being in an infested area.

a. Wear dark colored dresses Lyme disease is a vector-borne disease caused by the spirochete Borrelia burgdorferi and results from the bite of an infected deer tick, also known as the blacklegged tick. Light-colored, rather than dark-colored clothing is preferred to spot the ticks easily, thereby preventing an insect bite and infection. Wearing closed shoes and boots and tucking the shirt in the pants prevent the entry and the bite of the blacklegged tick. Bathing should be done immediately after being in an infested area to prevent any possible infection.

A client is admitted to the ED with joint pain and swelling. Upon assessment, the nurse suspects rheumatoid arthritis. Which findings support the nurse's conclusion? SATA. a. Obesity b. Antinuclear antibodies c. Inflammatory disease pattern d. Disease in the bilateral symmetric joints e. Disease in the distal intrapharyngeal joints f. Disease in the weight-bearing joints and hands

b. Antinuclear antibodies c. Inflammatory disease pattern d. Disease in the bilateral symmetric joints Rheumatoid arthritis is an autoimmune disorder identified by the presence of antinuclear antibodies. Disease in the bilateral symmetric joints is generally seen in rheumatoid arthritis. Rheumatoid arthritis involves inflammation of the joints. Osteoarthritis involves degeneration of the joints. Obesity is a risk factor for osteoarthritis. Osteoarthritis affects weight-bearing joints and the hands.

A client is admitted to the hospital with an acute episode of rheumatoid arthritis (RA) asks why physical therapy has not been prescribed. What is the most appropriate nursing response? a. "Your PCP must have forgotten to prescribe it." b. "Your condition is not severe enough to have physical therapy approved." c. "Your joints are still inflamed, and physical therapy can be harmful." d. "Physical therapy is not helpful for persons who suffer from RA."

c. "Your joints are still inflamed, and physical therapy can be harmful." Rest is required during active inflammation of the joints to prevent injury; once active inflammation has receded, an activity and exercise regimen can begin. Physical therapy is not prescribed during a period of exacerbation because it can traumatize already inflamed joints. The extent of the arthritis is not the determinant; whether the process is in exacerbation or remission is the deciding factor. Physical therapy is helpful, but it is not performed during an acute exacerbation of the arthritis.

After treatment for Lyme disease, a child expresses fear of going camping again because of the ticks. What is the best response by the nurse? a. "Tell me more about your fears about camping." b. "Just think of all the fun you'll be missing if you don't go to camp." c. "It's hard to believe you're afraid to go camping just because of a tick." d. "I understand you are afraid. Frequently checking for ticks can help prevent re-infection."

d. "I understand you are afraid. Frequently checking for ticks can help prevent re-infection." Explaining the usefulness of frequent checks for ticks identifies the concern and presents an appropriate protective intervention. Detection and prompt removal of ticks decreases the chances of the spread of Lyme disease to human beings. Asking the child to tell the nurse more about fears related to camping is an inappropriate response because it focuses on the wrong fear. Telling the child to think of all the fun that would be missed is incorrect because the response focuses on camping, not on the fear of ticks. Also, it belittles the child's fears. Saying that it's hard to believe that the child is afraid to go camping also belittles the child's feelings.

A nurse is taking the health hx of a client who is to have surgery in one week. The nurse identifies that the client is taking ibuprofen for discomfort associated with osteoarthritis and notifies the HCP. Which drug does the nurse expect will most likely be prescribed instead of the ibuprofen? a. Naproxen b. Aspirin c. Ketorolac d. Acetaminophen

d. Acetaminophen Acetaminophen is a nonopioid analgesic that inhibits prostaglandins, which serve as mediators for pain; it does not affect platelet function. Naproxen, aspirin, and ketorolac are nonselective nonsteroidal antiinflammatory drugs ( NSAIDs) that are contraindicated for clients undergoing surgery; nonselective NSAIDs have an inhibitory effect on thromboxane, a strong aggregating agent, and can result in bleeding.

A nurse plans care to prevent deformities in a client with rheumatoid arthritis. Which intervention should be alternated with periods of rest? a. Active exercises b. Passive massage c. Bracing of joints d. Isometric exercises

a. Active exercises Active exercises, alternated with periods of rest, offer the best chance at preventing the joint deformities associated with rheumatoid arthritis, because they can move each involved joint through its full range of motion. Massage affects the muscles, not the joints, and will do little to prevent deformities. Immobilization of joints by bracing will promote the formation of contractures and deformities. Isometric exercises will promote muscle, not joint, function.

Which conditions may result from immunoglobulin IgE antibodies on mast cells reacting with antigens? SATA. a. Asthma b. Hay fever c. Sarcoidosis d. Myasthenia gravis e. Rheumatoid arthritis

a. Asthma b. Hay fever Clinical conditions such as asthma and hay fever are considered type I hypersensitive reactions that are mediated by a reaction between IgE antibodies with antigens. It results in the release of mediators such as histamines. Type IV hypersensitivity reactions such as sarcoidosis result from reactions between sensitized T cells with antigens. Myasthenia gravis results from a type II hypersensitivity reaction that occurs due to an interaction between immunoglobulin IgG and the host cell membrane. Rheumatoid arthritis is a type III hypersensitivity reaction that results from the formation of immune complexes between antigens and antibodies that results in inflammation.

A client is admitted with full-blown anaphylactic shock that developed d/t a type 1 latex allergic reaction. Which findings will the nurse observe upon assessment? SATA. a. Stridor b. Fissuring c. Hypotension d. Dyspnea e. Cracking of the skin

a. Stridor c. Hypotension d. Dyspnea Full-blown anaphylactic shock produces stridor, hypotension, and dyspnea. Fissuring and cracking of the skin occurs in individuals with a type IV contact dermatitis.

A client experiences an acute episode of rheumatoid arthritis. The nurse observes that the client's finger joints are swollen. The nurse concludes that this swelling is most likely r/t which factor? a. Urate crystals in the synovial tissue b. Inflammation in the joint's synovial lining c. Formation of bony spurs on the joint surfaces d. Deterioration and loss of articular cartilage joints

b. Inflammation in the joint's synovial lining In rheumatoid arthritis, transformed autoantibodies attack synovium, producing inflammation. Urate crystals occur with gouty, not rheumatoid, arthritis. Formation of bony spurs on the joint surfaces is unrelated to rheumatoid arthritis. Deterioration and loss of articular cartilage in joints is osteoarthritis.

An older adult fell at home and fractured their left hip. Which response should the ED nurse identify as a typical clinical indicator associated with a fractured hip? a. Affected hip is ecchymotic b. Left leg is noticeably shorter than the right leg c. Left extremity is internally rotated d. Affected hip is tender when touched

b. Left leg is noticeably shorter than the right leg There is overriding of bones in the fractured hip, and the leg on the affected side appears noticeably shorter than the unaffected leg. Ecchymosis is evidence of soft tissue and blood vessel damage; this may or may not be associated with a fractured hip. The affected leg is externally, not internally, rotated with a fractured hip. Pain associated with a fractured hip is not mild; it causes extreme pain.

A client is experiencing an exacerbation of systemic lupus erythematosus. To reduce the frequency of exacerbations, what would be important for the nurse to include in the client's teaching plan? a. Basic principles of hygiene b. Techniques to reduce stress c. Measures to improve nutrition d. Signs of an impending exacerbation

b. Techniques to reduce stress Systemic lupus erythematosus is an autoimmune disorder, and physical and emotional stresses have been identified as contributing factors to the occurrence of exacerbations. Although basic principles of hygiene should be performed, inadequate hygiene is not known to produce exacerbations. Although measures to improve nutrition should be done, nutritional status is not significantly correlated to exacerbations. Knowledge of the symptoms will not decrease the occurrence of exacerbations.

A client with rheumatoid arthritis is to begin taking ibuprofen 800mg PO TID. The nurse provides education about the medication's side effects. The nurse concludes that the teaching was effective when the client makes which statement? a. "I need to have my blood work checked periodically." b. "I need to balance exercise with rest." c. "I need to change positions slowly." d. "I need to take the medication between meals."

a. "I need to have my blood work checked periodically." If the client will be taking the medication long term, periodic diagnostic tests are necessary because ibuprofen is nephrotoxic, is hepatotoxic, and prolongs the bleeding time. Balancing exercise with rest is important for all clients with arthritis; it is not related to ibuprofen. Ibuprofen does not cause postural hypotension. Ibuprofen causes epigastric distress and occult bleeding; it should be taken with meals or milk to reduce these adverse reactions.

A client with rheumatoid arthritis has been taking a steroid medication for the past year. For which complication of prolonged use of this medication should the nurse assess the client? a. Decreased WBCs b. Increased C-reactive protein c. Increased sedimentation rate d. Decreased serum glucose levels

a. Decreased WBCs Prolonged use of steroids may cause leukopenia as a result of bone marrow depression. C-reactive protein and sedimentation rate are elevated in acute inflammatory diseases; steroids help decrease it. Serum glucose levels increase with steroid use.

The nurse is providing education to a client with systemic lupus erythematosus. Which education will the nurse consider as high priority? a. Instructing the client about ways to protect the skin b. Helping the client to identify coping strategies c. Teaching methods to monitor body temperature d. Teaching about the effects of the disease on lifestyle

a. Instructing the client about ways to protect the skin A client with systemic lupus erythematosus is first taught to protect the skin to prevent infections. Helping the client with identifying coping strategies is given low priority. Different methods are taught to monitor body temperature because fever is a major sign of exacerbation. Teaching about the effects of the disease on lifestyle occurs after teaching ways to protect the skin.

A PCP schedules a bone scan for a client with osteoporosis. Which nursing actions are beneficial for the client? SATA. a. Placing the client in the supine position b. Verifying if the client has a shellfish allergy c. Ensuring that the client has no metal on the clothing d. Instructing the client to empty the bladder before the scan e. Informing the client that the postprocedure headache resolves in 2 days

a. Placing the client in the supine position d. Instructing the client to empty the bladder before the scan A bone scan is done to assess osteomyelitis, osteoporosis, primary and metastatic malignant lesions of bone, and certain fractures. The nurse has to place that client in the supine position for one hour for easy assessment while performing the bone scan. The nurse should instruct the client to empty the bladder before scanning. The client undergoing a computed tomography (CT) scan must be screened for a shellfish allergy to reduce the incidences of anaphylactic shock associated with the radiocontrast agent. Radio waves and a magnetic field are used during magnetic resonance imaging (MRI); therefore, the nurse should ensure that the client has no metal on the clothing before the procedure. The main risk of a myelogram is a spinal headache that usually resolves within 2 days of the procedure.

Which are examples of a type IV hypersensitivity reaction? SATA. a. Poison ivy allergic reaction b. Sarcoidosis c. Myasthenia gravis d. Rheumatoid arthritis e. Systemic lupus erythematosus

a. Poison ivy allergic reaction b. Sarcoidosis Sarcoidosis and poison ivy reactions are examples of type IV hypersensitivity reactions. In type IV hypersensitivity, the inflammation is caused by a reaction of sensitized T cells with the antigen and the resultant activation of macrophages due to lymphokine release. Myasthenia gravis is an example of a type II or cytotoxic hypersensitivity reaction. Rheumatoid arthritis and systemic lupus erythematosus are examples of type III immune complex-mediated reactions.

What condition does the nurse suspect from the image? a. Rash d/t tick bite b. Rash d/t bee sting c. Rash d/t bedbug bites d. Rash d/t body lice bites

a. Rash d/t tick bite Lyme disease, which is caused by a tick bite, is manifested as a spreading, ring-like rash with an erythematous border. The rash commonly occurs in the groin area, buttocks, axillae, trunk, upper arms, or legs. Bee stings cause intense, burning, local pain, swelling, and itching at the site. Bedbug bites are manifested as urticaria grouped in threes and surrounded by a vivid flare, transforming into a persistent lesion. Body lice bites manifest as minute, red, noninflammatory points flush with the skin, which progress to papular wheal-like lesions.

The nurse considers that a 70-year-old female client can best limit further progression of osteoporosis by doing what? a. Taking supplemental calcium and vitamin D b. Increasing consumption of eggs and cheese c. Taking supplemental magnesium and vitamin E d. Increasing the consumption of milk and milk products

a. Taking supplemental calcium and vitamin D Research demonstrates that women past menopause need at least 1500 mg of calcium a day, which is almost impossible to obtain through dietary sources; because the average daily consumption of calcium is 300 to 500 mg. Vitamin D promotes the deposition of calcium into the bone. Consumption of eggs and cheese does not contain adequate calcium to meet requirements to prevent osteoporosis; these do not contain vitamin D unless fortified. If large amounts of magnesium are present, calcium absorption is impeded because magnesium and calcium absorption are competitive; vitamin E is unrelated to osteoporosis. Milk and milk products may not be consumed in quantities adequate to meet requirements to prevent osteoporosis.

A nurse is performing an admission health hx and physical assessment for a client who has severe rheumatoid arthritis. When assessing the client's hands, the nurse identifies that they are similar to the hand in the illustration. What should the nurse document in the medical record when describing this typical physiologic change associated with rheumatoid arthritis? a. ulnar drift b. Hallux valgus c. Swan-neck deformity d. Boutonniere deformity

a. ulnar drift Ulnar drift occurs when the long axis of the fingers makes an angle with the long axis of the wrist so that the fingers are deviated to the ulnar side of the hand; it is caused by changes in the metacarpophalangeal joints. Hallux valgus occurs when the great toe is angulated away from the midline of the body toward the other toes. Swan-neck deformity occurs with flexion of the distal interphalangeal joint and hyperextension of the proximal interphalangeal joint. Boutonnière deformity occurs with fixed flexion of the proximal interphalangeal joint and hyperextension of the distal interphalangeal joint.

A client with a fracture is found to have compartment syndrome. Which interventions will be contraindicated? SATA. a. Splitting the cast in half b. Applying cold compresses c. Reducing the traction weight d. Loosening the client's bandage e. Elevating the extremity above heart level

b. Applying cold compresses e. Elevating the extremity above heart level Cold compresses and elevating above the heart level are contraindicated for compartment syndrome. Compartment syndrome is a condition in which swelling and increased pressure within a limited space (a compartment) press on and compromise the function of blood vessels, nerves, and tendons that run through that compartment. Application of cold compresses could result in vasoconstriction and exacerbate compartment syndrome. Elevating the extremity above heart level could lower venous pressure and slow arterial perfusion. Splitting the cast in half decreases pressure and is beneficial in treating compartment syndrome. Reducing traction weight is beneficial because it decreases external circumferential pressure. Loosening the bandage is beneficial because it decreases pressure.

Which emergency care actions are priority for a hospitalized client who develops an anaphylactic reaction after receiving a medication? SATA. a. Raise the feet and legs b. Assess respiratory status c. Call the rapid response team d. Discontinue the IV drug e. Keep the head of the bed elevated to 10º.

b. Assess respiratory status c. Call the rapid response team d. Discontinue the IV drug In cases of anaphylaxis, the client's respiratory status should immediately be assessed, including the airway and oxygen saturation. And the Rapid Response Team should be called right away. Immediate discontinuation of the drug responsible for the anaphylactic reaction is also necessary. Raising the client's feet and legs is an appropriate intervention but is not the priority. The head of the bed should be elevated to 10 degrees if hypotension is present.

Which nursing intervention is most appropriate for a client in skeletal traction? a. Add and remove weights as the client desires b. Assess the pin sites at least every shift and as needed c. Ensure that the knots in the rope are tied to the pulley. d. Perform range of motion to joints proximal and distal to the fracture at least once per day.

b. Assess the pin sites at least every shift and as needed Nursing care for a client in skeletal traction may include assessing pin sites every shift and as needed. The needed weight for a client in skeletal traction is prescribed by the physician, not as desired by the client. The nurse also should ensure that the knots are not tied to the pulley and move freely. The performance of range of motion is indicated for all joints except the ones proximal and distal to the fracture because this area is immobilized by the skeletal traction to promote healing and prevent further injury and pain

The nurse is preparing an individual teaching plan for a client with osteoarthritis. The nurse recognizes which abnormality specific to osteoarthritis? a. Ulnar drift b. Heberden nodes c. Swan-neck deformity d. Boutonniere deformity

b. Heberden nodes Heberden nodules are the bony or cartilaginous enlargements of the distal interphalangeal joints that are associated with osteoarthritis. Ulnar drift, swan-neck deformity, and boutonnière deformity occur with rheumatoid arthritis.

A client suffered an injury to the leg as a result of a fall. X-ray films indicate an intertrochanteric fracture of the femur. The client will be placed in buck traction until surgery is performed. When considering the client's plan of care, the nurse recalls that the primary purpose of Buck traction is to do what? a. Reduce the fracture b. Immobilize the fracture c. Maintain abduction of the leg d. Eliminate rotation of the femur

b. Immobilize the fracture A continuous pull on the lower extremity keeps bone fragments from moving and causing further trauma, pain, and edema. The fracture will be reduced by surgery; Buck traction is a temporary measure before surgery. Moving the leg away from the midline will not keep the leg in alignment; it is not the purpose of Buck traction. External rotation of the femur may still occur with Buck traction.

Which symptoms are observed in a client with Sjogren's syndrome? SATA. a. Angioedema b. Tooth decay c. Corneal ulcers d. Vaginal dryness e. Pulmonary hemorrhage

b. Tooth decay c. Corneal ulcers d. Vaginal dryness A client with Sjögren's syndrome (SS) may have antigens specific to certain tissue types, such as HLA-DRW52, HLA-DR3, and HLA-B8. Sjögren's syndrome may lead to autoimmune destruction of the lacrimal, salivary, and vaginal mucus-producing glands. Insufficient saliva decreases digestion of carbohydrates, which may promote tooth decay. Insufficient tears cause inflammation and ulceration of the cornea. Vaginal dryness increases the risk for infection and causes painful sexual intercourse. Angioedema occurs with a type I hypersensitivity reaction that may occur within seconds after exposure to the allergen. Clients with Goodpasture syndrome may have lung and kidney problems. Pulmonary hemorrhage is associated with this syndrome.

After providing epinephrine to a client experiencing an anaphylactic reaction, which second-line drugs should the nurse prepare to provide? SATA. a. Dopamine b. Norepinephrine c. Dexamethasone d. Diphenhydramine hydrochloride e. Hydrocortisone sodium succinate

c. Dexamethasone d. Diphenhydramine hydrochloride e. Hydrocortisone sodium succinate Dexamethasone is a corticosteroid that is a second-line drug used in the treatment of anaphylaxis. Diphenhydramine hydrochloride is an antihistamine that is a second-line drug used in the treatment of anaphylaxis. Hydrocortisone sodium succinate is a corticosteroid that is a second-line drug used in the treatment of anaphylaxis. Dopamine and norepinephrine are vasopressor medications and are considered support drugs in the treatment of anaphylaxis.

The nurse is assessing a client with severe nodule-forming rheumatoid arthritis for possible Felty syndrome. Which assessment findings are consistent with Felty syndrome? SATA. a. itchy eyes b. Dry mouth c. Leukopenia d. Splenomegaly e. Photosensitivity

c. Leukopenia d. Splenomegaly Felty syndrome occurs most commonly in clients with severe nodule-forming rheumatoid arthritis; it is characterized by splenomegaly and leukopenia. Itchy eyes, dry mouth, and photosensitivity are all signs of Sjögren syndrome.

What type of hypersensitivity reaction is the cause of systemic lupus erythematosus? a. Type I b. Type II c. Type III d. Type IV

c. Type III Systemic lupus erythematosus is an example of an immune complex-mediated, or type III, hypersensitive reaction. Anaphylaxis is an example of a type I or immediate hypersensitive reaction. Cytotoxic or type II hypersensitive reactions can result in conditions such as myasthenia gravis and Goodpasture syndrome. Graft rejection and sarcoidosis are conditions that are caused by delayed or type IV hypersensitivity reactions.

A client reports redness, itching, burning, and pain in the palms and elbows. Upon assessment, the nurse finds demarcated, silvery, scaling plaques in the area. Which drug does the nurse expect in the client's prescription? a. Oral famcyclovir b. IV ceftriaxone c. Topical benzoyl peroxide d. Intralesional injection of corticosteroids

d. Intralesional injection of corticosteroids Psoriasis is an autoimmune chronic dermatitis that is sharply demarcated with silvery, scaling plaques with reddish colored skin most often on palms and elbows. The main goal is to reduce inflammation and suppress rapid turnover of epidermal cells. Intralesional injection of corticosteroids is beneficial in treating chronic plaques. Famcyclovir is an antiviral that may be used to treat infections such as herpes zoster. Intravenous ceftriaxone may be used to treat severe cases of Lyme disease that include cardiac, arthritic, and neurologic symptoms. Topical benzoyl peroxide is an antimicrobial that may be used to treat conditions such as acne vulgaris.

A client with rheumatoid arthritis asks the nurse about ways to decrease morning stiffness. What should the nurse suggest? a. wearing loose, but warm clothing b. Planning a short rest break periodically c. Avoiding excessive physical stress and fatigue d. Taking a hot tub bath or shower in the morning

d. Taking a hot tub bath or shower in the morning Moist heat increases circulation and decreases muscle tension, which help relieve chronic stiffness. Although wearing loose but warm clothing is advisable for someone with arthritis, it does not relieve morning stiffness. Inactivity promotes stiffness. The practice of avoiding excessive physical stress and fatigue is related to muscle fatigue, not to stiffness of joints.