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A client with multiple sclerosis is admitted with an acute exacerbation. What is the nurse's priority action?
- A. Monitor the client's vital signs every hour.
- B. Assess for changes in the client's muscle strength.
- C. Administer prescribed corticosteroids to reduce inflammation.
- D. Educate the client on managing fatigue and preventing relapses.
Correct Answer: C
Rationale: The correct answer is C. Administering prescribed corticosteroids to reduce inflammation is the priority action when a client with multiple sclerosis is admitted with an acute exacerbation. Corticosteroids help manage symptoms during exacerbations and reduce inflammation. Monitoring vital signs and assessing muscle strength are important aspects of care but not the priority during an acute exacerbation. Educating the client on managing fatigue and preventing relapses is essential but can be addressed after the acute exacerbation has been managed.
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A client with hypertension is prescribed a thiazide diuretic. What dietary recommendation should the nurse make?
- A. Encourage a diet low in carbohydrates and fats.
- B. Avoid foods high in vitamin K, such as spinach and kale.
- C. Increase salt intake to prevent dehydration.
- D. Eat potassium-rich foods like bananas and oranges.
Correct Answer: D
Rationale: The correct answer is D: 'Eat potassium-rich foods like bananas and oranges.' Thiazide diuretics can lead to potassium loss, so it is essential for clients to consume potassium-rich foods to maintain adequate levels. Choice A is incorrect because focusing solely on low carbohydrates and fats does not address the specific issue of potassium loss. Choice B is unrelated as vitamin K content is not a concern with thiazide diuretics. Choice C is incorrect as increasing salt intake would exacerbate hypertension and not prevent dehydration.
The client is being taught about precautions with Coumadin therapy. The client should be instructed to avoid which over-the-counter medication?
- A. Non-steroidal anti-inflammatory drugs
- B. Cough medicines containing guaifenesin
- C. Histamine blockers
- D. Laxatives containing magnesium salts
Correct Answer: A
Rationale: The correct answer is A: Non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs can increase the risk of bleeding in clients taking Coumadin, which is an anticoagulant medication. Avoiding NSAIDs helps prevent potentially dangerous interactions with Coumadin. Choices B, C, and D are incorrect. Cough medicines with guaifenesin, histamine blockers, and laxatives containing magnesium salts do not typically have significant interactions with Coumadin therapy. Therefore, they are not the over-the-counter medications that the client needs to avoid while on Coumadin.
A client with liver cirrhosis is receiving lactulose for hepatic encephalopathy. Which finding indicates the medication is effective?
- A. The client's level of consciousness improves.
- B. The client's ammonia level decreases.
- C. The client has three bowel movements daily.
- D. The client's liver enzymes return to normal.
Correct Answer: B
Rationale: The correct answer is B: "The client's ammonia level decreases." In hepatic encephalopathy, elevated ammonia levels contribute to neurological symptoms. Lactulose works by promoting the excretion of ammonia in the stool, leading to decreased serum ammonia levels. Therefore, a decrease in ammonia levels indicates that lactulose is effectively reducing ammonia buildup, improving hepatic encephalopathy symptoms. Choices A, C, and D are incorrect because improvement in level of consciousness, bowel movements, or normalization of liver enzymes may not directly reflect the effectiveness of lactulose in reducing ammonia levels and improving hepatic encephalopathy.
A client presses the call bell and requests pain medication for a severe headache. To assess the quality of the client's pain, which approach should the nurse use?
- A. Use the Wong-Baker Faces pain rating scale
- B. Assess vital signs to gauge pain severity
- C. Ask the client to describe the pain
- D. Offer a 1-10 pain scale
Correct Answer: C
Rationale: Asking the client to describe the pain is the most appropriate approach to assess the quality of pain. It provides valuable qualitative information that aids in understanding the nature, cause, and potential management strategies for the headache. While pain rating scales like the Wong-Baker Faces scale and using vital signs can help quantify pain severity, they do not offer specific descriptive details that can give insights into the type and characteristics of the pain experienced by the client.
The nurse is evaluating the laboratory reports of a client with hypothyroidism. The nurse would expect which of the following laboratory values?
- A. Increased TSH
- B. Increased thyroxine (T4)
- C. Decreased TSH
- D. Decreased T3
Correct Answer: A
Rationale: The correct answer is A: Increased TSH. In hypothyroidism, the thyroid gland is underactive, leading to low levels of thyroid hormones. As a compensatory mechanism, the pituitary gland releases more thyroid-stimulating hormone (TSH) to try to stimulate the thyroid gland to produce more hormones. Therefore, increased TSH levels are expected in hypothyroidism. Choice B is incorrect because in hypothyroidism, thyroxine (T4) levels are usually decreased, not increased. Choice C is incorrect as hypothyroidism is characterized by increased TSH levels, not decreased. Choice D is also incorrect because in hypothyroidism, T3 levels may be decreased, but TSH is a more sensitive indicator for diagnosis.