Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client with chronic fatigue syndrome.
Which of the following criteria were used to assist in making this diagnosis? Select all that apply.
A. Not caused by a primary condition.
Choice A is correct because CFS is not caused by a primary condition. CFS is a diagnosis of exclusion, meaning that other possible causes of fatigue, such as sleep disorders, anaemia, diabetes, thyroid problems, or mental health issues, must be ruled out before making the diagnosis.
B. Recent exposure to influenza.
Choice B is wrong because recent exposure to influenza is not a criterion for CFS diagnosis. Although some cases of CFS may be triggered by viral infections, such as Epstein-Barr virus or human herpes virus 6, there is no specific evidence that influenza causes CFS.
C. Unrefreshed after adequate sleep.
Choice C is correct because unrefreshing sleep is one of the required symptoms for CFS diagnosis. Patients with CFS may not feel better or less tired even after a full night of sleep despite the absence of specific objective sleep alterations.
D. Not relieved by stress reduction.
Choice D is correct because fatigue that is not relieved by stress reduction is another required symptom for CFS diagnosis. Patients with CFS experience post-exertional malaise (PEM), which means that their symptoms worsen after physical, mental, or emotional exertion that would not have caused a problem before the illness.
E. Severe tiredness for 2 months or more.
Choice E is correct because severe tiredness for 2 months or more is one of the additional manifestations that must be present for CFS diagnosis. The IOM 2015 report states that the fatigue associated with CFS must last for more than 6 months and occur at least half the time at moderate, substantial or severe intensity.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom Sp23 N144 FINAL Proctored Exam. Take the full exam now
Full Explanation
These are some of the criteria used to assist in making the diagnosis of chronic fatigue syndrome (CFS) according to the Institute of Medicine (IOM) 2015 report.
Choice B is wrong because recent exposure to influenza is not a criterion for CFS diagnosis. Although some cases of CFS may be triggered by viral infections, such as Epstein-Barr virus or human herpes virus 6, there is no specific evidence that influenza causes CFS.
Choice A is correct because CFS is not caused by a primary condition. CFS is a diagnosis of exclusion, meaning that other possible causes of fatigue, such as sleep disorders, anemia, diabetes, thyroid problems, or mental health issues, must be ruled out before making the diagnosis.
Choice C is correct because unrefreshing sleep is one of the required symptoms for CFS diagnosis. Patients with CFS may not feel better or less tired even after a full night of sleep despite the absence of specific objective sleep alterations. Choice D is correct because fatigue that is not relieved by stress reduction is another required symptom for CFS diagnosis. Patients with CFS experience post-exertional malaise (PEM), which means that their symptoms worsen after physical, mental, or emotional exertion that would not have caused a problem before the illness.
Choice E is correct because severe tiredness for 2 months or more is one of the additional manifestations that must be present for CFS diagnosis. The IOM 2015 report states that the fatigue associated with CFS must last for more than 6 months and occur at least half the time at moderate, substantial or severe intensity.
Similar Questions
An elderly client is hospitalized for the first time.
Which of the following actions ensures the safety of the client? (Select all that apply).
A. Keep call bell within the client’s reach.
Keeping a call bell within the client’s reach allows them to ask for help when needed.
B. Keep a dim light on at night.
Keeping a dim light on at night helps them orient themselves and see their surroundings.
C. Keep unnecessary furniture out of the way.
Keeping unnecessary furniture out of the way prevents tripping and cluttering.
D. Keep all side rails up at all times.
Choice D is wrong because keeping all side rails up at all times can be considered a form of physical restraint, which is associated with many professional, legal and ethical challenges. Physical restraint should only be used as a last resort when other alternatives have failed or are not feasible. Keeping all side rails up can also increase the risk of injury if the client tries to climb over them.
E. Keep all lights off at night.
Choice E is wrong because keeping all lights off at night can increase the risk of falls and confusion for the client. Older adults may have impaired vision and cognition, and they may need to use the bathroom frequently at night. Keeping all lights off can make it difficult for them to find their way and increase their anxiety.
Full Explanation
These actions ensure the safety of the client by reducing the risk of falls, confusion and injury.
Keeping a call bell within the client’s reach allows them to ask for help when needed.
Keeping a dim light on at night helps them orient themselves and see their surroundings.
Keeping unnecessary furniture out of the way prevents tripping and cluttering. Choice D is wrong because keeping all side rails up at all times can be considered a form of physical restraint, which is associated with many professional, legal and ethical challenges. Physical restraint should only be used as a last resort when other alternatives have failed or are not feasible. Keeping all side rails up can also increase the risk of injury if the client tries to climb over them.
Choice E is wrong because keeping all lights off at night can increase the risk of falls and confusion for the client.
Older adults may have impaired vision and cognition, and they may need to use the bathroom frequently at night. Keeping all lights off can make it difficult for them to find their way and increase their anxiety.
The nurse is performing a cultural assessment with a client; the nurse should include which of the following? (Select All That Apply).
A. Review all ordered treatments in relation to the client’s culture.
A cultural assessment is a systematic way to identify the beliefs, values, meanings, and behaviors of people while considering their history, life experiences, and social and physical environments. A nurse should include reviewing all ordered treatments in relation to the client’s culture and listening to the client’s perceptions as part of a cultural assessment.
B. Listen to the client’s perceptions.
A cultural assessment is a systematic way to identify the beliefs, values, meanings, and behaviors of people while considering their history, life experiences, and social and physical environments. A nurse should include reviewing all ordered treatments in relation to the client’s culture and listening to the client’s perceptions as part of a cultural assessment.
C. Explain the purpose of the treatments, without regard to the client’s culture.
Choice C is wrong because explaining the purpose of the treatments without regard to the client’s culture may be insensitive or inappropriate for some clients who have different beliefs or practices about health and illness.
D. Acknowledge that the client will have to adapt their perceptions to the dominant culture.
Choice D is wrong because acknowledging that the client will have to adapt their perceptions to the dominant culture may be disrespectful or oppressive for some clients who value their cultural identity and diversity.
Full Explanation
A cultural assessment is a systematic way to identify the beliefs, values, meanings, and behaviours of people while considering their history, life experiences, and social and physical environments. A nurse should include reviewing all ordered treatments in relation to the client’s culture and listening to the client’s perceptions as part of a cultural assessment.
These actions show respect for the client’s preferences and facilitate communication and understanding.
Choice C is wrong because explaining the purpose of the treatments without regard to the client’s culture may be insensitive or inappropriate for some clients who have different beliefs or practices about health and illness. Choice D is wrong because acknowledging that the client will have to adapt their perceptions to the dominant culture may be disrespectful or oppressive for some clients who value their cultural identity and diversity.
A nurse is caring for a patient who has complaints of fatigue.
If the fatigue is caused by lifestyle choices, what should the nurse recommend for fatigue prevention? (Select all that apply)
A. Maintain a regular sleep routine.
Choice A is correct because maintaining a regular sleep routine can help regulate your circadian rhythm, which is your body’s natural sleep-wake cycle. This can improve the quality and quantity of your sleep and reduce daytime sleepiness.
B. Eat 3 large meals a day.
Choice B is wrong because eating three large meals a day can cause fluctuations in your blood sugar levels, which can affect your energy levels. It is better to eat smaller, more frequent meals and snacks that contain a balance of protein and carbohydrates to keep your blood sugar stable and provide sustained energy.
C. Limit refined sugar, fried foods, and processed foods.
Choice C is correct because limiting refined sugar, fried foods and processed foods can help prevent fatigue by reducing inflammation and oxidative stress in your body. These foods can also cause spikes and crashes in your blood sugar levels, which can make you feel tired and hungry. Instead, you should eat more anti-inflammatory foods, such as fruits, vegetables, nuts, seeds and fish.
D. Take daily walks.
Choice D is correct because taking daily walks can help prevent fatigue by increasing your blood circulation, oxygen delivery and endorphin production. Exercise can also improve your mood, sleep quality and immune system
E. Take more coffee.
Choice E is wrong because increasing caffeine intake can have the opposite effect of preventing fatigue. Caffeine is a stimulant that can temporarily boost your energy levels, but it can also disrupt your sleep, cause dehydration, increase anxiety and lead to withdrawal symptoms
Full Explanation
Choice A is correct because maintaining a regular sleep routine can help regulate your circadian rhythm, which is your body’s natural sleep-wake cycle. This can improve the quality and quantity of your sleep and reduce daytime sleepiness.
Choice B is wrong because eating three large meals a day can cause fluctuations in your blood sugar levels, which can affect your energy levels. It is better to eat smaller, more frequent meals and snacks that contain a balance of protein and carbohydrates to keep your blood sugar stable and provide sustained energy. Choice C is correct because limiting refined sugar, fried foods and processed foods can help prevent fatigue by reducing inflammation and oxidative stress in your body.
These foods can also cause spikes and crashes in your blood sugar levels, which can make you feel tired and hungry. Instead, you should eat more anti-inflammatory foods, such as fruits, vegetables, nuts, seeds and fish.
Choice D is correct because taking daily walks can help prevent fatigue by increasing your blood circulation, oxygen delivery and endorphin production. Exercise can also improve your mood, sleep quality and immune system.
Choice E is wrong because increasing caffeine intake can have the opposite effect of preventing fatigue.
Caffeine is a stimulant that can temporarily boost your energy levels, but it can also disrupt your sleep, cause dehydration, increase anxiety and lead to withdrawal symptoms