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The client diagnosed with multiple sclerosis is scheduled for a magnetic resonance imaging (MRI) scan of the head. Which information should the nurse teach the client about the test?
- A. The client will have wires attached to the scalp and lights will flash off and on.
- B. The machine will be loud and the client must not move the head during the test.
- C. The client will drink a contrast medium 30 minutes to one (1) hour before the test.
- D. The test will be repeated at intervals during a five (5)- to six (6)-hour period.
Correct Answer: B
Rationale: MRI machines are loud, and head immobility is critical for clear images. Wires/lights describe EEG, oral contrast is not used for brain MRI, and the test is not repeated over hours.
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The client diagnosed with RA has developed swan-neck fingers. Which referral is most appropriate for the client?
- A. Physical therapy.
- B. Occupational therapy.
- C. Psychiatric counselor.
- D. Home health nurse.
Correct Answer: B
Rationale: Occupational therapy addresses hand function and adaptive devices for swan-neck deformities. Physical therapy, counseling, and home health are less specific.
The male client diagnosed with multiple sclerosis states he has been investigating alternative therapies to treat his disease. Which intervention is most appropriate by the nurse?
- A. Encourage the therapy if it is not contraindicated by the medical regimen.
- B. Tell the client only the health-care provider should discuss this with him.
- C. Ask how his significant other feels about this deviation from the medical regimen.
- D. Suggest the client research an investigational therapy instead.
Correct Answer: A
Rationale: Encouraging safe alternative therapies supports autonomy if they align with medical treatment. Deferring to HCP, involving significant other, or suggesting investigational therapies are less appropriate.
The nurse and a female unlicensed assistive personnel (UAP) are caring for a group of clients on a medical floor. Which action by the UAP warrants immediate intervention by the nurse?
- A. The UAP washes her hands before and after performing vital signs on a client.
- B. The UAP dons sterile gloves prior to removing an indwelling catheter from a client.
- C. The UAP raises the head of the bed to a high Fowler's position for a client about to eat.
- D. The UAP uses a fresh plastic bag to get ice for a client's water pitcher.
Correct Answer: B
Rationale: Sterile gloves are unnecessary for catheter removal, risking improper technique and infection. Handwashing, Fowler’s position, and ice bag use are appropriate.
The client diagnosed with Multi Organ Dysfunction Syndrome (MODS) has renal, cardiovascular, and pulmonary dysfunction issues. Which statement by the nurse indicates an understanding of the client's prognosis?
- A. As long as the client is maintained on a ventilator, then the prognosis can be up to 60% recovery.
- B. The client will have less than a 2% potential for recovery from the MODS.
- C. When three or more body systems fail, the mortality rate can be 70% to 80%.
- D. More than one body system in failure reduces the recovery rate to 80% to 90%.
Correct Answer: C
Rationale: MODS with three or more organ failures has a 70–80% mortality rate. Ventilator use, 2% recovery, and 80–90% recovery are inaccurate.
The client in the HCP's office is complaining of allergic rhinitis. Which assessment question is important for the nurse to ask the client?
- A. What time of year do the symptoms occur?
- B. Which over-the-counter medications have you tried?
- C. Do other members of your family have allergies to animals?
- D. Why do you think you have allergies?
Correct Answer: A
Rationale: Seasonal patterns help identify allergic rhinitis triggers. Medications, family history, and client beliefs are secondary.