Nokea
The client with RA has nontender, movable nodules in the subcutaneous tissue over the elbows and shoulders. Which statement is the scientific rationale for the nodules?
- A. The nodules indicate a rapidly progressive destruction of the affected tissue.
- B. The nodules are small amounts of synovial fluid that have become crystallized.
- C. The nodules are lymph nodes which have proliferated to try to fight the disease.
- D. The nodules present a favorable prognosis and mean the client is better.
Correct Answer: B
Rationale: RA nodules are granulomas, sometimes containing synovial fluid, due to chronic inflammation. They do not indicate rapid destruction, lymph node proliferation, or better prognosis.
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Which signs/symptoms make the nurse suspect the most common opportunistic infection in the female client diagnosed with acquired immunodeficiency syndrome (AIDS)?
- A. Fever, cough, and shortness of breath.
- B. Oral thrush, esophagitis, and vaginal candidiasis.
- C. Abdominal pain, diarrhea, and weight loss.
- D. Painless violet lesions on the face and tip of nose.
Correct Answer: A
Rationale: Fever, cough, and shortness of breath indicate Pneumocystis pneumonia, the most common AIDS opportunistic infection. Candidiasis, GI symptoms, and Kaposi’s sarcoma are less frequent.
The client recently diagnosed with SLE asks the nurse, 'What is SLE and how did I get it?' Which statement best explains the scientific rationale for the nurse's response?
- A. SLE occurs because the kidneys do not filter antibodies from the blood.
- B. SLE occurs after a viral illness as a result of damage to the endocrine system.
- C. There is no known identifiable reason for a client to develop SLE.
- D. This is an autoimmune disease that may have a genetic or hormonal component.
Correct Answer: D
Rationale: SLE is an autoimmune disease with genetic and hormonal influences. Kidney issues are a complication, viral triggers are secondary, and the cause is partially understood.
The nurse is planning the care for a client diagnosed with RA. Which intervention should be implemented?
- A. Plan a strenuous exercise program.
- B. Order a mechanical soft diet.
- C. Maintain a keep-open IV.
- D. Obtain an order for a sedative.
Correct Answer: C
Rationale: A keep-open IV ensures access for RA medications (e.g., biologics). Strenuous exercise worsens joints, soft diets are unrelated, and sedatives are not routine.
The nurse in the emergency department is allergic to latex. Which intervention should the nurse implement regarding the use of nonsterile gloves?
- A. Use only sterile, nonlatex gloves for any procedure requiring gloves.
- B. Do not use gloves when starting an IV or performing a procedure.
- C. Keep a pair of nonsterile, nonlatex gloves in the pocket of the uniform.
- D. Wear white cotton gloves at all times to protect the hands.
Correct Answer: C
Rationale: Carrying nonsterile, nonlatex gloves ensures safe practice for a latex-allergic nurse. Sterile gloves are unnecessary, avoiding gloves risks infection, and cotton gloves are inadequate.
The client with myasthenia gravis is undergoing plasmapheresis at the bedside. Which assessment data warrant immediate intervention?
- A. The client's BP is 94/60 and AP is 112.
- B. Negative Chvostek's and Trousseau's signs.
- C. The serum potassium level is 3.5 mEq/L.
- D. Ecchymosis at the vascular site access.
Correct Answer: A
Rationale: Hypotension (BP 94/60) and tachycardia (AP 112) during plasmapheresis suggest hypovolemia or reaction, requiring immediate intervention. Negative signs, normal potassium, and ecchymosis are less urgent.