Nokea
The client diagnosed with Systemic Response Inflammatory Syndrome (SIRS) asks the nurse what the diagnosis means. Which is the nurse's best response?
- A. SIRS is a localized response to major trauma that has occurred within the last three (3) months.
- B. SIRS is a syndrome of potential responses to illness that has an optimum prognosis.
- C. SIRS is a respiratory response to the client having had a myocardial infarction or pneumonia.
- D. SIRS is a systemic response to a variety of insults, including infection, ischemia, and injury.
Correct Answer: D
Rationale: SIRS is a systemic response to insults like infection or trauma. It is not localized, has variable prognosis, and is not solely respiratory.
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Which assessment data should make the nurse suspect the client has chronic allergies?
- A. Jaundiced sclera and jaundiced palms of hands.
- B. Pale, boggy, edematous nasal mucosa.
- C. Lacy white plaques on the oral mucosa.
- D. Purple or blue patches on the face.
Correct Answer: B
Rationale: Pale, boggy, edematous nasal mucosa indicates chronic allergic rhinitis. Jaundice, oral plaques, and facial patches suggest other conditions.
Which statement by the client supports the diagnosis of Guillain-Barré syndrome?
- A. I just returned from a short trip to Japan.
- B. I had a really bad cold just a few weeks ago.
- C. I think one of the people I work with had this.
- D. I have been taking some herbs for more than a year.
Correct Answer: B
Rationale: A recent viral infection (e.g., cold) is a common trigger for Guillain-Barré syndrome. Travel, coworker illness, and herbs are less relevant.
The nurse enters the room of a female client diagnosed with SLE and finds the client crying. Which statement is the most therapeutic response?
- A. I know you are upset, but stress makes the SLE worse.
- B. Please explain to me why you are crying.
- C. I recommend going to an SLE support group.
- D. I see you are crying. We can talk if you would like.
Correct Answer: D
Rationale: Acknowledging crying and offering to talk is therapeutic, encouraging emotional expression. Linking stress to SLE, demanding explanations, or suggesting groups are less supportive.
The client newly diagnosed with multiple sclerosis (MS) states, 'I don't understand how I got multiple sclerosis. Is it genetic?' On which statement should the nurse base the response?
- A. Genetics may play a role in susceptibility to MS, but the disease may be caused by a virus.
- B. There is no evidence suggesting there is any chromosomal involvement in developing MS.
- C. Multiple sclerosis is caused by a recessive gene, so both parents had to have the gene for the client to get MS.
- D. Multiple sclerosis is caused by an autosomal dominant gene on the Y chromosome, so only fathers can pass it on.
Correct Answer: A
Rationale: MS has a genetic susceptibility component (e.g., HLA genes), but environmental factors like viral infections may trigger it. There is chromosomal involvement, MS is not purely recessive or dominant, and it is not Y-linked.
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.