Nur 215 Medical Surgical 1

Correct Answer:

“Monitor for tendon pain.”

Explanation:

Ciprofloxacin, a fluoroquinolone antibiotic, carries a black box warning for tendonitis and tendon rupture, particularly in older adults and those on corticosteroids. Patients should be instructed to report any new tendon pain, swelling, or inflammation, especially in the Achilles tendon. Early recognition and discontinuation of the drug can prevent further injury. Monitoring for musculoskeletal symptoms is a vital part of ciprofloxacin safety education.

Why Other Options Are Wrong:

“Take this medication with an antacid.”

This is incorrect because antacids containing magnesium or aluminum can interfere with ciprofloxacin absorption. Patients should be instructed to separate ciprofloxacin from antacids by several hours.

“Limit fluid intake while on this medication.”

Fluids should not be restricted while taking ciprofloxacin. In fact, maintaining adequate hydration is encouraged to prevent crystalluria and support renal function.

“Expect urine to turn dark orange.”

This is an expected side effect of phenazopyridine (Pyridium), not ciprofloxacin. Ciprofloxacin does not typically discolor urine, so this would be misleading.

Correct Answer:

Keep active, use stress-reduction strategies and avoid fatigue

Explanation:

Even for patients on bed rest, encouraging as much activity as tolerated helps reduce complications like muscle atrophy, pressure injuries, and respiratory issues. For patients with an indwelling catheter, stress and fatigue can also impair immune function and recovery. Stress-reduction and energy conservation strategies are essential to preserve physical and mental well-being during limited mobility. Maintaining a positive, proactive approach to care supports recovery.

Why Other Options Are Wrong:

Follow good health habits to change the course of the disease

This does not directly address the immediate nursing concern for a patient with a catheter and on bed rest. It is vague and not a priority intervention.

Practice using the mechanical aids that you will need with future disabilities arise

This statement assumes future decline and is not patient-centered or timely. The focus should be on current needs and abilities.

You will need to accept the necessity of a quiet and inactive lifestyle

This promotes passivity and can worsen physical deconditioning. Bed rest should be managed with interventions that promote safe mobility and prevent complications.

Correct Answer:

Glomerulus

Explanation:

Proteinuria, or the presence of excess protein in the urine, typically indicates damage to the glomerulus. The glomerulus acts as a filter in the nephron, allowing waste products to pass while retaining larger molecules like proteins. Damage to this filtration barrier allows proteins to leak into the urine, which is a hallmark of glomerular injury.

Why Other Options Are Wrong:

Renal artery

While the renal artery supplies blood to the kidney, it is not directly involved in filtration. Damage here would affect perfusion but not cause protein leakage unless it results in downstream glomerular damage.

Collecting ducts

The collecting ducts primarily function in water and electrolyte reabsorption under hormonal control. They do not filter blood or retain protein, so damage here would not result in proteinuria.

Loop of Henle

This structure plays a role in concentrating urine by reabsorbing water and salts. It does not serve as a filtration site for proteins, so damage here is unlikely to result in protein in the urine.

Correct Answer:

Strike a flat hand covering the costovertebral angle (CVA)

Explanation:

Assessment for costovertebral angle (CVA) tenderness is a standard method for evaluating flank pain, often associated with kidney infection such as pyelonephritis. The nurse places one hand flat over the CVA region and strikes it with the fist of the other hand. A positive response is pain or discomfort, indicating possible inflammation or infection in the kidney. This is a quick, non-invasive method to support diagnostic decisions.

Why Other Options Are Wrong:

Palpate along both sides of the lumbar vertebral column

Palpation can assess muscle or skeletal tenderness but is not specific or reliable for evaluating kidney inflammation or infection.

Push fingers upward into the two lowest intercostal spaces

This technique is not relevant to kidney assessment. It may be used in abdominal exams but does not target the CVA where the kidneys are located.

Percuss between the iliac crest and ribs at the midaxillary line

Although this area may be near the CVA, this technique does not accurately localize kidney tenderness and is not the standard method for assessing flank pain related to pyelonephritis.

Correct Answer:

Drooping eye lids

Explanation:

Ptosis, or drooping eyelids, is a hallmark symptom of myasthenia gravis due to the autoimmune destruction of acetylcholine receptors, leading to skeletal muscle weakness. Ocular symptoms such as ptosis and diplopia often appear first, especially after sustained muscle use. The weakness worsens with activity and improves with rest, which is characteristic of this disease. Recognizing early signs like ptosis is crucial for diagnosis and timely management.

Why Other Options Are Wrong:

Peripheral edema

This is not associated with myasthenia gravis. Edema is more common in conditions related to fluid imbalance, heart failure, or kidney dysfunction.

Loss of cognitive function

Myasthenia gravis affects motor neurons, not cognitive processing. Patients typically maintain normal mental status unless affected by unrelated conditions or medication side effects.

Fluctuations in heart rate

While autonomic symptoms can occur in some advanced neuromuscular disorders, they are not a common feature of myasthenia gravis. Heart rate variability is not expected in routine cases.

Correct Answer:

Hesitancy

Nocturia

Dysuria

Incomplete emptying

Hematuria

Explanation:

Lower urinary tract infection (UTI) typically presents with localized symptoms related to bladder irritation and incomplete bladder emptying. These include dysuria (painful urination), hesitancy (difficulty starting urination), nocturia (frequent urination at night), incomplete emptying, and sometimes hematuria (blood in the urine). These symptoms result from inflammation of the bladder and urethra due to bacterial invasion, most commonly by E. coli.

Why Other Options Are Wrong:

Fever

Fever is more common in upper UTIs (such as pyelonephritis). Lower UTIs may not cause systemic signs like fever unless they progress.

Chills

Chills are also typically associated with systemic infection or upper urinary tract involvement. They are not hallmark signs of lower UTI alone.

Correct Answer:

Lateral recumbent with chin resting on flexed knees

Explanation:

The lateral recumbent position with the patient’s back arched and chin resting on flexed knees allows maximum separation of the vertebrae. This positioning facilitates access to the subarachnoid space for the lumbar puncture. It also helps the patient remain still during the procedure, reducing the risk of needle misplacement. Correct positioning is essential to ensure safety and obtain accurate cerebrospinal fluid (CSF) samples.

Why Other Options Are Wrong:

Prone with the head turned to the right

The prone position does not adequately separate the vertebrae and is not standard for lumbar puncture. It also makes needle placement more difficult and less controlled.

Supine with the knees raised toward the chest

This position does not offer the same degree of spinal flexion as the lateral recumbent position. It is not ideal for accessing the lumbar subarachnoid space.

Prone with right leg flexed

Again, the prone position is incorrect for this procedure, and flexing just one leg does not aid spinal access. This posture may actually increase patient discomfort without benefit.

Correct Answer:

Mobility

Nutrition

Sensory perception

Moisture

Explanation:

The Braden Scale is a validated tool used to assess a patient's risk for developing pressure injuries. It includes six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. These categories help evaluate the patient’s functional ability and skin integrity risk. Mobility, nutrition, sensory perception, and moisture are all core components that directly influence skin health and pressure injury risk.

Why Other Options Are Wrong:

Pain

Pain is not one of the official subscales of the Braden Scale. Although pain may influence a patient's activity or behavior, it is not scored directly within this risk assessment tool.

Correct Answer:

It does not alter the underlying disease process, but it may improve a client’s quality of life

Explanation:

Carbidopa/levodopa is a cornerstone medication for managing the symptoms of Parkinson’s disease. It does not modify or reverse the disease itself, as Parkinson’s is a progressive neurodegenerative disorder. Instead, the medication helps restore dopamine balance in the brain, which can significantly reduce motor symptoms such as tremors, stiffness, and slowness of movement. By relieving symptoms, it can greatly enhance the patient's quality of life even though the disease continues to progress.

Why Other Options Are Wrong:

It will send the disease into remission and eventually cure the disease

This is inaccurate because Parkinson’s disease is chronic and progressive. There is currently no known cure or remission phase for the disease, and medications only manage symptoms. This option creates a false sense of expectation about treatment outcomes.

It will control the symptoms for 10 to 12 years

While carbidopa/levodopa is initially effective, its long-term use is often associated with diminishing returns and complications like motor fluctuations and dyskinesias. The specific duration of symptom control varies and is not guaranteed for 10–12 years.

It is the treatment of last resort and may control symptoms

Carbidopa/levodopa is actually considered first-line therapy in many cases, especially when symptoms significantly impair functioning. Labeling it as a “treatment of last resort” is misleading and clinically incorrect.