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SIMCLEX #1A nurse is caring for a client with generalized muscle pain, sleep disturbances and constant
diarrhea. After multiple tests show no concrete cause, the nurse knows that this client is
likely suffering from which of the following?
Myasthenia gravis
This has a known cause, which is a chronic, progressive disorder that causes a disconnect
between the peripheral nervous system and the muscles.
Failure to thrive
This is a diagnosis usually given to children who are not meeting adequate growth
standards.
Fibromyalgia
This condition has no known cause at this time. It is characterized by muscle pain and
weakness.
Guillain Barre syndrome
This is an autoimmune disorder that can be caused by infection or possibly the flu vaccine.
Please drag answers into the 3 blanks below to complete the paragraph: A client began is
experiencing chest pain and developed a third-degree AV block. The client is emergently
taken to the cardiac catheterization lab. The nurse anticipates that the mostly likely cause of
the new AV block is due to blockage in the right coronary artery that supplies blood to the AV
nodes, ..... and .....
The left main coronary artery supplies blood to the left ventricle and left atrium. The left
anterior descending (LAD) artery and the circumflex artery are both branches off the left
coronary artery. The LAD supplies blood to the interventricular septum, left anterior surface
of the heart while the circumflex artery supplies blood to the lateral and posterior heart. The
right coronary artery (RCA) supplies blood the right atrium and ventricle, the SA node, the
AV node,
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A nurse works in a hospital that has developed a culture of safety as described by the Joint
Commission. Which elements would be included as part of developing this type of
environment? Select all that apply.
Safety is everyone's first priority
A culture of safety helps provide safe and effective client care. It emphasizes transparency
and a non-punitive approach to reporting and learning from adverse events, close calls, and
unsafe conditions.
Behaviors that undermine the culture of safety are addressed in a non-punitive way
A culture of safety is described by the Joint Commission as a way to provide safe care to
clients. To develop a culture of safety, the hospital would ensure that safety is a priority and
educate others about the importance of upholding safe practices in a non-punitive
environment. When staff members don't feel afraid to report their own errors, it results in an
increased reporting of errors, and a better chance to address and fix them. This greatly
increases safety in an organization.
Staff are committed to promptly changing unsafe conditions
Safety is a top priority when a culture of safety is adopted by organizations. This means that
staff recognize the importance
A nurse is assessing a client who is being admitted to the hospital from home for knee
surgery. Which part of the assessment would be included with an admission assessment but
not with a routine focused assessment?
Assessment of the cause of the client's knee injury
A comprehensive assessment is one that is performed as an initial assessment at
admission. Alternatively, a focused assessment is performed to assess a specific area and is
done when a change in the client's status has occurred, such as the following surgery.
Asking about what caused the injury would not be repeated regularly, but only when
gathering history on admission.
Assessment of knee range of motion
Assessment of the client's pain
Assessment of the client's vital signs
These are done as part of the focused assessment of the client, and would be done with
every nursing assessment going forward in this client's situation.
,vcg
A nurse is caring for a client receiving fluoroquinolones for a respiratory infection. The client
begins to have severe burning pain. This concerns the nurse because the nurse knows that
which of the following types of ruptures could be occurring as a side effect of this
medication?
Aortic
Fluoroquinolones can use tear or rupture to the aorta as a cardiovascular side effect.
Which best describes how elevated stress levels in a client can worsen symptoms of acute
coronary syndrome?
Too much stress leads to platelet activation and endothelial dysfunction
Acute and chronic stress has a negative impact on health and can lead to worsening of
cardiac diseases. Acute mental stress leads to platelet activation and endothelial
dysfunction, which ultimately affects arteries, especially the coronary artery to increase CAD.
Chronic stress can lead to chronic inflammation in the vascular system as well. This
inflammation can weaken the vessels and can increase the risk of plaque rupture, which can
cause an embolus if part of the plaque travels through the bloodstream and lodges in
another vessel.
Stress causes poor perfusion of the distal extremities
Stress causes blood clots in the microvasculature of internal organs
Too much stress leads to poor muscle tone and decreased activity tolerance
-Stress does not cause these side effects.
The parents of a 4-year-old are concerned that their child is not on target with developmental
activities. Which activity should the nurse recommend that the parents observe for to
determine if this child is developing appropriately?
The child is dressing without much help
When parents are concerned about physical development, the nurse can assess whether
the child is able to perform certain tasks before considering further evaluation. A 4-year-old
child should typically be learning how dress and undress independently, brush teeth, and
walk up and down stairs without help.
The child is losing her baby teeth
, This begins to happen around age 6.
The child learns to tie shoes
This begins to happen around ages 6-8
The child can go up the stairs holding a hand
This begins to happen around ages 2-3.
A nurse is caring for a 4 year-old child with nausea and vomiting. The child is lethargic,
reporting pain in the stomach and being very tired, and has just vomited. What is the nurse’s
priority concern for this child?
Airway clearance
Any time a client has vomiting accompanied by lethargy, aspiration is a concern. Maintaining
a patent airway is essential and will always be a priority. **Test taking tip: Remember your
ABC's!
Electrolyte balance
While the child could possibly experience an electrolyte imbalance due to excessive
vomiting, the priority will always be to maintain a patent airway.
Nutritional status
The impact of vomiting on nutritional status in an acute setting is minimal, therefore it would
certainly not take priority over airway.
Fluid volume status
The child is likely dehydrated and will certainly need rehydration. However, maintaining a
patent airway (A-airway) will always take priority over volume (C-circulation).
The nurse caring for a child diagnosed with the measles knows that which of the following
are classic symptoms of this diagnosis?
Coryza, cough, conjunctivitis
These are known as the 3 C’s and are a classic triad of symptoms associated with the
diagnosis of measles.
Polydipsia, polyuria, polyphagia
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