Special Populations Primary Care for the Advanced Practice Nurse (D120)

Correct answer C. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column

Explanation:

Brudzinski's sign is a clinical indicator of meningeal irritation, often associated with meningitis. When the nurse flexes the client's neck, a positive response occurs if the client involuntarily flexes the hips and knees. This reflexive action is due to the irritation of the meninges and spinal nerves, causing pain along the vertebral column. This test, along with Kernig’s sign, is commonly used in the assessment of suspected meningitis.

Why other options are wrong:

A. The client rigidly extends the arms with pronounced forearms and plantar flexion of the feet. This describes decerebrate posturing, which is seen in severe brain injury, not a positive Brudzinski's sign.

B. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. This describes Kernig’s sign, another test for meningeal irritation, but it is not Brudzinski’s sign.

D. The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated. This describes decorticate posturing, which indicates damage to the corticospinal tract, not meningitis.

Correct answer B. Smoked salami.

Explanation:

Smoked and processed meats, such as salami, contain high amounts of sodium due to the curing and preservation process. Excess sodium intake contributes to hypertension by increasing fluid retention and blood pressure.

Why other options are wrong:

A. Fresh fish. While some canned or smoked fish may be high in sodium, fresh fish itself is naturally low in sodium and can be part of a heart-healthy diet.

C. Raw vegetables. Fresh vegetables are naturally low in sodium and are encouraged in a diet for managing hypertension. However, processed vegetables with added salt (e.g., canned soups) can be high in sodium.

D. Whole grains. Whole grains, such as brown rice, quinoa, and whole wheat bread, are typically low in sodium unless processed or flavored with added salt. These are recommended in a balanced diet for hypertension management.

Correct answer:

A. Administer phosphate supplements as prescribed

Explanation:

A serum phosphorus level of 1.5 mg/dL is below the normal range (2.5 to 4.5 mg/dL) and indicates hypophosphatemia, which is commonly seen in clients with chronic alcoholism. Alcoholism can cause malnutrition, poor phosphate absorption, and increased renal losses of phosphate. Severe hypophosphatemia can lead to muscle weakness, confusion, respiratory depression, and cardiac dysfunction. Administering phosphate supplements as prescribed helps restore phosphorus levels and prevent complications.

Why other options are wrong:

B. Monitor the client for signs of renal failure

Although phosphorus imbalances can occur with renal failure, chronic kidney disease usually leads to hyperphosphatemia (high phosphorus levels) due to decreased excretion. In this case, the client's low phosphorus level is more likely due to chronic alcoholism and malnutrition, not renal failure. Monitoring kidney function is important, but it is not the priority intervention.

C. Educate the client on dietary sources of phosphorus

While dietary phosphorus intake is important, food sources alone may not be sufficient to correct severe hypophosphatemia. Clients with chronic alcoholism often have poor dietary intake and absorption, making supplementation the primary intervention. Education on phosphorus-rich foods (dairy, nuts, meats) is useful but should be secondary to immediate correction.

D. Assess the client for symptoms of hyperparathyroidism

Hyperparathyroidism typically leads to hypercalcemia and hypophosphatemia due to increased phosphorus excretion by the kidneys. However, in this client, chronic alcoholism is the most likely cause of the low phosphorus level, not a parathyroid disorder. While it is essential to assess for underlying causes, treating the immediate deficiency takes precedence.

Correct answer C: They reflect the appropriate anticoagulation effect of heparin.

Explanation:

Activated partial thromboplastin time (aPTT) is a laboratory test used to monitor the effectiveness of heparin therapy. A therapeutic range of 1.5 to 2.5 times the normal aPTT value (typically 25-35 seconds) ensures effective anticoagulation without excessive bleeding risk. A range between 45 and 100 seconds indicates that heparin is sufficiently prolonged clotting time to prevent further clot formation while minimizing the danger of uncontrolled bleeding.

Why other options are wrong:

A. They indicate a risk of bleeding.

While prolonged aPTT values can increase bleeding risk, a therapeutic range between 45 and 100 seconds is considered safe and necessary for preventing clot progression in deep vein thrombosis (DVT). An aPTT significantly above this range, however, could indicate an elevated bleeding risk.

B. They ensure the medication is ineffective.

If aPTT levels were within the normal range (25-35 seconds), it would suggest that heparin was not effectively prolonging clotting time. However, an aPTT between 45 and 100 seconds confirms that the medication is functioning as intended.

D. They suggest the need for increased dosage of heparin.

If aPTT values were below 45 seconds, it might indicate that the heparin dose is insufficient. However, since the range of 45-100 seconds is considered therapeutic, there is no need to increase the dosage unless the value is consistently at the lower end or falls below the target range.

Correct answer B. They are a good source of iron.

Explanation:

Dark green leafy vegetables, such as spinach, kale, and Swiss chard, are rich in non-heme iron, which helps increase iron levels in individuals with iron deficiency anemia. Iron is an essential component of hemoglobin, the protein in red blood cells responsible for carrying oxygen throughout the body. Consuming iron-rich foods helps replenish iron stores and improve red blood cell production, reducing symptoms such as fatigue and weakness. To enhance absorption, it is recommended to consume these vegetables with vitamin C-rich foods, as non-heme iron is less easily absorbed than heme iron found in animal products.

Why other options are wrong:

A. They contain high levels of calcium.

While some dark green leafy vegetables contain calcium, calcium can actually inhibit iron absorption when consumed in large amounts. The presence of oxalates in some greens, such as spinach, may also reduce the bioavailability of iron. Therefore, calcium is not the primary reason these vegetables are recommended for individuals with iron deficiency anemia.

C. They are low in calories.

Although dark green leafy vegetables are low in calories, this characteristic does not directly address the needs of individuals with iron deficiency anemia. Low-calorie foods may be beneficial for weight management, but the priority for anemia management is increasing iron intake rather than reducing calorie consumption.

D. They provide essential fatty acids.

Dark green leafy vegetables contain small amounts of essential fatty acids, such as omega-3s, but these nutrients are not the primary reason they are recommended for anemia. Essential fatty acids are beneficial for heart and brain health, but they do not significantly impact iron levels or red blood cell production.

Correct answer:

D. They reflect an increase in gastrointestinal motility due to low sodium.

Explanation:

Hyponatremia (low sodium levels) can lead to increased gastrointestinal motility, resulting in hyperactive bowel sounds. Sodium plays a crucial role in nerve impulse transmission, and when levels drop, it can lead to neuromuscular irritability, which may increase peristalsis and cause diarrhea or frequent bowel movements.

Why other options are wrong:

A. They indicate increased fluid retention in the intestines. While hyponatremia can cause fluid shifts, it does not specifically lead to fluid retention in the intestines. Fluid imbalances in hyponatremia primarily affect cells and extracellular compartments rather than directly increasing bowel sounds.

B. They suggest a decrease in sodium levels affecting nerve function. While sodium does affect nerve function, decreased sodium typically leads to muscle weakness, confusion, or seizures rather than directly causing hyperactive bowel sounds. The increase in bowel sounds is due to increased motility, not just nerve dysfunction.

C. They are a sign of dehydration due to high sodium levels. This answer incorrectly associates hyperactive bowel sounds with high sodium levels. Hyponatremia, not hypernatremia, is the condition being discussed. Additionally, dehydration is usually linked with sluggish bowel activity rather than hyperactive sounds.

Correct answer B. It may indicate a bruise related to physical abuse, warranting further investigation.

Explanation:

A reddish-purple mark on the neck could be a bruise resulting from physical trauma, including strangulation or other forms of abuse. In emergency and clinical settings, healthcare providers must be vigilant in assessing potential signs of domestic violence or assault. Strangulation injuries, in particular, can be life-threatening and may not always be immediately apparent. Prompt evaluation, documentation, and referral to social services are critical steps in ensuring the client’s safety.

Why other options are wrong:

A. It suggests a common skin condition that requires treatment.

While some skin conditions, such as rashes or birthmarks, may present with discoloration, a bruise on the neck is not a typical sign of a skin disorder requiring dermatologic treatment. Instead, it raises concerns about trauma or abuse, necessitating further inquiry into the client’s history and circumstances.

C. It is a normal finding in many individuals and does not require follow-up.

A reddish-purple mark, especially on the neck, is not a normal finding and should never be dismissed without investigation. Even if the client does not disclose abuse, healthcare providers must assess for patterns of injury and consider the possibility of harm before ruling out the need for intervention.

D. It is often associated with allergic reactions and should be treated accordingly.

While allergic reactions can cause skin changes, they typically present as hives, swelling, or rashes rather than localized bruising. A bruise on the neck, particularly without a clear medical explanation, warrants careful evaluation for potential physical trauma rather than being attributed to an allergic response.

Correct answer C. Vitamin C

Explanation:

Vitamin C plays a crucial role in wound healing because it is essential for collagen synthesis, a key component of skin and connective tissue repair. It also acts as an antioxidant and helps in immune function, reducing the risk of infection in healing wounds. Citrus fruits, such as oranges, lemons, and grapefruits, are rich sources of vitamin C, making them beneficial for wound recovery.

Why other options are wrong:

A. Vitamin A. While vitamin A is important for skin health and immune function, it is not the primary vitamin involved in collagen formation and wound healing like vitamin C.

B. Vitamin B12. Vitamin B12 is essential for nerve function and red blood cell production, but it does not play a direct role in collagen synthesis and wound healing.

D. Vitamin D. Vitamin D is necessary for bone health and calcium absorption but does not significantly contribute to wound healing or collagen formation.

Correct answer B: To clarify the client assignment with the team leader

Explanation:

A nurse’s primary legal obligation when floating to an unfamiliar unit is to ensure patient safety while practicing within their scope of competence. Clarifying the client assignment with the team leader allows the nurse to receive appropriate assignments that match their skills and experience. This step helps mitigate risks, ensures patient care is not compromised, and demonstrates professional responsibility. Nurses are expected to advocate for safe assignments while also fulfilling their duty to provide care.

Why other options are wrong:

A. To refuse the assignment based on lack of experience

Refusing an assignment outright without attempting to clarify responsibilities may be seen as patient abandonment, which could have legal and professional consequences. While nurses should not accept assignments beyond their competency, they should first communicate their concerns with the appropriate personnel before making a decision.

C. To review the hospital's floating policy with the supervisor

While reviewing policies can provide valuable guidance, it does not fulfill the immediate legal obligation of ensuring safe patient care. Policies may outline procedures, but the priority in a floating situation is to communicate with the team leader and clarify expectations to prevent unsafe practices.

D. To submit a complaint to nursing administration

Filing a complaint does not address the immediate concern of ensuring safe patient care. While complaints may be necessary in cases of unsafe staffing practices, they are a secondary action that should be taken after clarifying the assignment and ensuring patients are not put at risk. The nurse’s primary duty is to address concerns in real time to maintain patient safety.