A client has had multiple sclerosis (MS) for 15 years and has received various drug therapies. What is the primary reason why the nurse has found it difficult to evaluate the effectiveness of the drugs that the client has used?
- A. The client exhibits intolerance to many drugs.
- B. The client experiences spontaneous remissions from time to time.
- C. The client requires multiple drugs simultaneously.
- D. The client endures long periods of exacerbation before the illness responds to a particular drug.
Correct Answer: B
Rationale: Spontaneous remissions in MS make it challenging to attribute symptom improvement to drugs versus natural disease course. Intolerance, multiple drugs, or delayed responses are less primary factors.
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The nurse finds the client who has had an ileostomy crying. The client explains to the nurse, 'I'm upset because I know I won't be able to have children now that I have an ileostomy.' Which of the following would be the best response for the nurse?
- A. Many women with an ileostomy can still have children; let's discuss your concerns with your doctor.
- B. Having an ileostomy does prevent pregnancy, but you can explore adoption.
- C. This is a common feeling; would you like to talk more about it?
- D. I'll RAW arrange for a counselor to discuss your fertility options.
Correct Answer: A
Rationale: The nurse should reassure the client that many women with ileostomies can still have children and offer to discuss this with the doctor, addressing the misconception directly. The other options either reinforce the misconception, avoid the concern, or defer without providing immediate support. CN: Psychosocial adaptation; CL: Synthesize
Which information should the nurse include when performing discharge teaching with a client who had an anterolateral approach for a total hip replacement? Select all that apply.
- A. Avoid turning the toes or knee outward.
- B. Use an abduction pillow between the legs when in bed.
- C. Use an elevated toilet seat and shower chair.
- D. Do not extend the operative leg backwards.
- E. Restrict motion for 2 weeks after surgery.
Correct Answer: A,B,C,D
Rationale: These measures prevent dislocation and promote recovery. Motion is encouraged, not restricted, to aid rehabilitation.
A 28-year-old client with cancer is afraid of experiencing a febrile reaction associated with blood transfusions. He asks the nurse if this will happen to him. The nurse's best response is which of the following?
- A. Febrile reactions are caused when antibodies on the surface of blood cells in the transfusion are directed against antigens of the recipient.
- B. Febrile reactions can usually be prevented by administering antipyretics and antihistamines before the start of the transfusion.
- C. Febrile reactions are rarely immune-mediated and can be a sign of hemolytic transfusion.
- D. Febrile reactions primarily occur within 15 minutes after initiation of the transfusion and can occur during the blood transfusion.
Correct Answer: B
Rationale: Febrile reactions can often be prevented with premedication like antipyretics and antihistamines, which is a reassuring and accurate response for the client.
The client who had a permanent pacemaker implanted 2 days earlier is being discharged from the hospital. The client understands the discharge plan when the client:
- A. Selects a low-cholesterol diet to control coronary artery disease.
- B. States a need for bed rest for 1 week after discharge.
- C. Verbalizes safety precautions needed to prevent pacemaker malfunction.
- D. Explains signs and symptoms of myocardial infarction (MI).
Correct Answer: C
Rationale: Understanding safety precautions (e.g., avoiding strong electromagnetic fields) prevents pacemaker malfunction, indicating discharge plan comprehension.
A client with cirrhosis begins to develop ascites. Spironolactone (Aldactone) is prescribed to treat the ascites. The nurse should monitor the client closely for which of the following drug-related adverse effects?
- A. Constipation.
- B. Hyperkalemia.
- C. Irregular pulse.
- D. Dysuria.
Correct Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic, so hyperkalemia (B) is a key adverse effect. Constipation (A), irregular pulse (C), and dysuria (D) are not typical.
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