"Nursing Practice 4" is a crucial area of study for the Nurse Licensure Examination (NLE), emphasizing the care of clients with complex physiologic and psychosocial alterations in Part B. This section specifically covers topics related to the Inflammatory Response, Immunologic Response, Cellular Aberrations, and Acute Biologic Crisis.
In this context, nurses learn to assess and manage conditions involving inflammatory processes, such as infections, autoimmune disorders, and systemic inflammatory response syndrome (SIRS). Understanding the immunologic response is vital for addressing immune system disorders like allergies, immunodeficiencies, and hypersensitivity reactions.
Furthermore, nurses study cellular aberrations, focusing on abnormal cellular growth, proliferation, and function seen in conditions like cancer and hematologic disorders. The management of acute biologic crises, such as anaphylaxis, sepsis, and hematologic emergencies, requires rapid intervention and critical thinking skills.
"Nursing Practice 4" equips nurses with the knowledge and skills necessary to provide safe and effective care to clients experiencing complex alterations in health. Mastery of these topics is essential for success in the Nurse Board Exam and in providing competent nursing care in clinical practice.
Nursing Practice 4 Reviewer
Welcome to our Nursing Practice 4 Practice Examination! In this session, you'll have the opportunity to test your understanding of key concepts in Nursing Practice 3. The quiz consists of multiple-choice questions covering various topics. Pay close attention to each question and select the best answer. After completing the exam, check the video below for the answer key and explanations.
SITUATION:
A 55-year-old female client is admitted to the hospital with a diagnosis of severe sepsis secondary to a urinary tract infection. The client presents with fever, hypotension, tachycardia, and altered mental status. Laboratory results indicate leukocytosis and elevated serum lactate levels, suggesting tissue hypoperfusion.
1. What is the primary pathophysiological mechanism underlying the client's condition?
A) Excessive fluid intake
B) Overactive immune response leading to systemic inflammation
C) Decreased production of white blood cells
D) Impaired blood clotting factors
2. Which assessment finding is most concerning in this client?
A) Hypotension
B) Altered mental status
C) Fever
D) Leukocytosis
3. What is the priority nursing intervention for managing this client's condition?
A) Administering antibiotics and intravenous fluids
B) Providing pain relief medications
C) Initiating deep breathing exercises
D) Restricting fluid intake
4. Which complication of severe sepsis should the nurse monitor for in this client?
A) Hypertension
B) Acute kidney injury
C) Hyperglycemia
D) Bradycardia
5. What nursing diagnosis is most appropriate for this client's condition?
A) Risk for Ineffective Tissue Perfusion
B) Risk for Impaired Skin Integrity
C) Risk for Imbalanced Nutrition: Less Than Body Requirements
D) Risk for Falls
SITUATION:
A 30-year-old male client with a history of systemic lupus erythematosus (SLE) is admitted to the hospital with complaints of joint pain, fatigue, and a butterfly rash on the face. The client reports difficulty breathing and chest pain. Upon assessment, the nurse notes decreased breath sounds on the left side and a rapid heart rate.
1. What immunologic process is likely contributing to the client's symptoms?
A) Autoimmune attack on lung tissue
B) Allergic reaction to medication
C) Immunosuppression leading to infection
D) Immune complex deposition in the lungs
2. Which manifestation is characteristic of a pleural effusion, a potential complication in this client?
A) Butterfly rash on the face
B) Joint pain and fatigue
C) Decreased breath sounds on auscultation
D) Rapid heart rate
3. What diagnostic test is essential for confirming a pleural effusion in this client?
A) Complete blood count (CBC)
B) Electrocardiogram (ECG)
C) Chest X-ray or ultrasound
D) Urinalysis
4. Which intervention is a priority for managing respiratory distress in this client?
A) Administering antihistamines to reduce allergic reactions
B) Initiating oxygen therapy and monitoring respiratory status
C) Encouraging increased fluid intake
D) Administering corticosteroids to suppress the immune response
5. What nursing diagnosis is most appropriate for this client's condition?
A) Impaired Skin Integrity related to rash and joint pain
B) Ineffective Breathing Pattern related to pleural effusion
C) Risk for Infection related to immunosuppression
D) Acute Pain related to chest discomfort
SITUATION:
A 60-year-old male client is admitted to the oncology unit for treatment of acute myeloid leukemia (AML). The client presents with weakness, fatigue, and easy bruising. Laboratory results reveal pancytopenia, with low red blood cells, white blood cells, and platelets. The client is scheduled to undergo chemotherapy to target abnormal hematopoietic cells.
1. What is the underlying pathophysiological mechanism of pancytopenia in this client with acute myeloid leukemia (AML)?
A) Overproduction of red blood cells
B) Suppression of bone marrow function
C) Excessive platelet destruction
D) Autoimmune attack on white blood cells
2. Which assessment finding is most concerning in this client?
A) Easy bruising
B) Fatigue
C) Low red blood cell count
D) Low white blood cell count
3. What is the priority nursing intervention for this client to prevent bleeding complications?
A) Encouraging increased physical activity
B) Administering anticoagulant medications
C) Implementing bleeding precautions
D) Providing high-calorie diet
4. What complication should the nurse monitor for during chemotherapy treatment in this client?
A) Increased hemoglobin levels
B) Neutropenic fever
C) Elevated platelet count
D) Improved bone marrow function
5. What nursing diagnosis is most appropriate for this client's condition?
A) Risk for Falls related to weakness and fatigue
B) Risk for Infection related to immunosuppression
C) Impaired Skin Integrity related to easy bruising
D) Altered Nutrition: Less Than Body Requirements related to anorexia
SITUATION:
A 45-year-old female client is brought to the emergency department with signs and symptoms of anaphylaxis following a bee sting. The client presents with generalized hives, facial swelling, wheezing, and difficulty breathing. The client is anxious and reports feeling lightheaded.
1. What is the primary immunologic mechanism underlying the client's condition?
A) Autoimmune attack on respiratory tissues
B) Overactive inflammatory response to the bee venom
C) Impaired blood clotting factors
D) Excessive fluid intake
2. What is the immediate nursing priority for managing this client's condition?
A) Administering antihypertensive medications
B) Providing oxygen therapy and monitoring respiratory status
C) Initiating intravenous fluid infusion
D) Applying cold compresses to reduce swelling
3. Which medication is the first-line treatment for anaphylaxis in this client?
A) Antibiotics
B) Corticosteroids
C) Antihistamines
D) Epinephrine (adrenaline)
4. What additional intervention should the nurse implement to manage the client's airway?
A) Administering bronchodilators
B) Initiating endotracheal intubation
C) Placing the client in a supine position
D) Preparing for emergency tracheostomy
5. What nursing diagnosis is most appropriate for this client's condition?
A) Risk for Impaired Gas Exchange related to airway obstruction
B) Anxiety related to allergic reaction
C) Risk for Infection related to systemic inflammation
D) Acute Pain related to bee sting
WATCH THE VIDEO FOR THE ANSWER KEY AND EXPLANATION