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NCLEX-Day-6 Questions with Explanations of Answers
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NCLEX-Day-6 Questions with Explanations of Answers
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Musculoskeletal injuriesMusculoskeletal injuries and immobilization devices (cast) can cause neurologic or vascular damage to the
extremity distal to the injury. Paresthesia (eg, numbness, tingling) is an early sign of neurovascular impairment
(nerve ischemia).
Ruptured Cerebral Aneurysm
- A ruptured cerebral aneurysm is a surgical emergency with a high mortality rate. Cerebral aneurysms are
usually asymptomatic unless they rupture; they are often called "silent killers" as they may go undetected for
many years before rupturing without warning signs.
- The distinctive description of a cerebral aneurysm rupture is the abrupt onset of "the worst headache of my
life" that is different from previous headaches (including migraines).
- Immediate evaluation for a possible ruptured aneurysm is critical for any client experiencing a severe
headache with changes in or loss of consciousness, neurologic deficits, diplopia (double vision), seizures,
vomiting, or a stiff neck.
- Early identification and prompt surgical intervention help increase the chance for survival.
Sjogren’s syndrome
- Sjögren's syndrome is an autoimmune condition. It causes inflammation of the exocrine glands (eg, lacrimal,
salivary), resulting in decreased production of tears and saliva and leading to dry eyes (xerophthalmia) and dry
mouth (xerostomia).
- Treatment with over-the-counter, preservative-free artificial tears can relieve eye dryness, burning, itching,
irritation, pain, and a gritty sensation in the eyes. Wearing goggles can protect the eyes from outdoor wind and
dust. Dry mouth is treated with artificial saliva. Using a room humidifier and not sitting in front of fans and
air vents can also help.
Scleroderma
Thickening of the skin occurs
Fibromyalgia
Multiple tender points are characteristic with this
Ankylosing spondylitis
Early morning back stiffness is associated with this
Mechanical ventilation & Suction
To minimize removal of oxygen and mucosal trauma, suction should be applied only when removing the
catheter, not when inserting it. Other interventions to reduce the risks associated with suctioning (eg,
hypoxemia, microatelectasis, cardiac dysrhythmias) include assessment for the need to suction, preoxygenating
with 100% oxygen, and limiting suction time to 10-15 seconds.
Troponin & MI
- Troponin is a cardiac specific serum marker that is a highly specific indicator of MI and has greater
sensitivity and specificity for myocardial injury than creatine kinase (CK) or CK-MB.
- Serum levels of troponin T and I increase 4-6 hours after the onset of MI, peak at 10-24 hours, and return to
baseline in 10-14 days.
- However, MI is not diagnosed alone by serum cardiac markers. Electrocardiogram findings and client health
history along with a history of pain and risk factors are also used to make the diagnosis of MI.
D-Dimer & PE
D-dimer is a laboratory test that measures the amount of cross-linked fibrin fragments resulting from clot
degradation. It is ordered for clients with suspected pulmonary embolism.
, Hypertension
- Chronic high blood pressure can result in coronary artery disease, stroke, heart failure, and kidney disease.
- Appropriate teaching should be provided to help clients manage their high blood pressure and control their
modifiable risk factors (eg, weight loss, Dietary Approaches to Stop Hypertension [DASH] diet, sodium
reduction, alcohol limitation, increased physical activity, smoking cessation).
Myoglobin & MI
Myoglobin is released into the circulation within 2 hours after MI. Although it may be the first serum cardiac
marker to appear after MI, it lacks cardiac specificity and its role in diagnosing MI is limited.
Blood Pressure & Pulse
- In healthy, well-hydrated people, blood pressure and pulse do not significantly alter with a change in position.
- In the normal mechanism, vasoconstriction prevents large amounts of blood from pooling in the extremities
when standing up.
- When a person is significantly dehydrated, vasoconstriction has already occurred: a loss of about 25% of
blood volume is necessary for hypotension to occur. Therefore, there is no compensation capacity available in a
dehydrated client with position change, and dropping blood pressure and rising pulse result.
- A drop in systolic blood pressure of at least 20 mm Hg or diastolic blood pressure of at least 10 mm Hg with
position change from lying to sitting to standing is considered postural (orthostatic) hypotension. Clients with
positive results are at risk for falling. If the client is symptomatic or findings are significantly abnormal, the
evaluation should stop without completing all the measurements.
Mastectomy & Lymph Node
- Ordinarily, lymph nodes are not palpable in adults. However, a lymph node that is palpable, superficial,
small (0.5-1 cm), mobile, firm, and nontender is considered a normal finding. It could easily be explained
by the relatively recent mastectomy (trauma) with resulting inflammation and lymph flow interference.
- A tender, hard, fixed, or enlarged node is an abnormal finding. Tender nodes are usually due to
inflammation, but hard or fixed nodes could indicate malignancy.
Celiac disease
- An assessment of the client's food intake must be obtained to determine if it includes foods that contain gluten,
a protein in barley, rye, oats, and wheat (mnemonic: BROW). The most common reason for non-
responsiveness to a gluten-free diet in clients with celiac disease is that gluten has not been entirely eliminated
from their food intake.
- Most people experience dramatic relief of gastrointestinal symptoms within a few days of eliminating gluten
from their diet.
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