Question 1:

A nurse is caring for a group of elderly clients in a long-term care facility. One client, known for his mischievous behavior, keeps hiding his dentures. Despite thorough searches, the dentures seem to disappear regularly. Which of the following interventions should the nurse implement to address this issue?

A) Conducting hourly room checks to locate the missing dentures

B) Implementing a denture tracking system with GPS technology

C) Providing the client with an alternative chewing gum for comfort

D) Engaging the client in a game of "Hide and Seek" to find the dentures

Answer:

A) Conducting hourly room checks to locate the missing dentures

Rationale: While the situation may seem amusing, the priority is to ensure the client's dentures are located promptly to prevent discomfort and potential oral health issues.₂ Conducting hourly room checks allows the nursing staff to systematically search for the missing dentures and ensure they are returned to the client in a timely manner. This intervention addresses the issue effectively by prioritizing the client's comfort and oral care needs.

Question 2:

A 25-year-old patient presents with a cluster of painful, fluid-filled blisters on the upper lip. The patient reports having a similar episode a year ago. Which of the following is the most likely causative agent?

A) Varicella-zoster virus

B) Herpes simplex virus-1

C) Epstein-Barr virus

D) Cytomegalovirus

Answer:

B) Herpes simplex virus-1

Rationale: Herpes simplex virus-1 (HSV-1) is the most common cause of orolabial herpes, also known as cold sores or fever blisters. The clinical presentation of a cluster of painful, fluid-filled blisters on the upper lip, along with a history of a similar episode, is characteristic of HSV-1 infection.₃

A. Varicella-zoster virus is incorrect because it causes chickenpox and shingles, not orolabial herpes.

C. Epstein-Barr virus is incorrect because it causes infectious mononucleosis, not orolabial herpes.

D. Cytomegalovirus is incorrect because it typically causes more severe systemic illness, not orolabial herpes.

Question 3:

A 65-year-old male patient presents to the emergency department with complaints of chest pain, shortness of breath, and diaphoresis. The patient denies taking any daily medications. His vital signs are as follows: blood pressure 160/90 mmHg, heart rate 110 bpm, respiratory rate 24 breaths/min, and oxygen saturation 92% on room air. An electrocardiogram (ECG) reveals ST-segment elevation in leads II, III, and aVF. The nurse suspects an acute myocardial infarction (MI) and prepares to administer thrombolytic therapy.

Which of the following assessments is the nurse's priority before administering thrombolytic therapy?

A) Auscultate lung sounds for crackles.

B) Assess peripheral pulses bilaterally.

C) Obtain a blood pressure reading from both arms.

D) Verify the patient's recent history of anticoagulant use.

Answer:

A) Auscultate lung sounds for crackles.

Rationale: Before administering thrombolytic therapy to a patient suspected of having an acute myocardial infarction (MI), it is crucial for the nurse to assess lung sounds for crackles. Thrombolytic therapy carries the risk of causing bleeding complications, including intracranial hemorrhage and pulmonary hemorrhage. Auscultating lung sounds helps to identify any signs of pulmonary congestion or edema, which may indicate pre-existing conditions such as heart failure.₁ Presence of crackles could suggest the presence of pulmonary edema, which is a contraindication for thrombolytic therapy due to the increased risk of bleeding. Therefore, assessing lung sounds is the priority to ensure patient safety and appropriate treatment decisions.

1  Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Camera, I. M. (2022). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (12th Edition). Elsevier.

2  Douglass, C. W., & Shih, A. (2002). Dental health and access to dental care among older adults in long-term care facilities. Journal of Public Health Dentistry, 62(1), 1-7.

3  Grillner, L., & Blomgren, J. (2018). Herpes simplex virus infections. In J. Cohen, W. G. Powderly, & S. M. Opal (Eds.), Infectious Diseases (4th ed., pp. 1184-1194). Elsevier.