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A nurse is caring for a client who has systemic lupus erythematosus. During assessment, which of the following should the nurse expect to find?
- A. Joint inflammation
- B. Bull's eye lesion
- C. Esophagitis
- D. Tophi
Correct Answer: A
Rationale: The correct answer is A: Joint inflammation. Systemic lupus erythematosus commonly affects the joints, leading to inflammation and pain. This is known as lupus arthritis. Other choices are incorrect: B (Bull's eye lesion) is associated with Lyme disease, C (Esophagitis) is inflammation of the esophagus which is not a common manifestation of lupus, and D (Tophi) are uric acid crystal deposits seen in gout, not lupus.
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A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?
- A. Ask a family member to be present during the admission.
- B. Request an interpreter during the initial assessment.
- C. Familiarize themselves with commonly used sign language.
- D. Obtain a board that uses colored pictures as communication.
Correct Answer: B
Rationale: The correct answer is B: Request an interpreter during the initial assessment. This is the most appropriate action as it ensures effective communication between the nurse and the client who uses sign language. It upholds the client's right to clear and accurate information regarding their care. Asking a family member (choice A) may not guarantee accurate communication and could breach confidentiality. Familiarizing oneself with sign language (choice C) takes time and may not be sufficient for complex medical discussions. Using a board with pictures (choice D) may not provide the client with the level of detail needed for comprehensive care. Overall, requesting an interpreter is the best choice for ensuring effective communication and respecting the client's rights.
A nurse is planning care for a client who has a new diagnosis of acute pancreatitis. Which of the following interventions should the nurse include in the plan of care?
- A. Administer antihypertensive medications.
- B. Maintain the client on NPO status.
- C. Place the client in a supine position.
- D. Monitor the client for hypercalcemia.
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on NPO status. In acute pancreatitis, the pancreas is inflamed, and digestion should be minimized to reduce pancreatic enzyme secretion. Keeping the client on NPO status allows the pancreas to rest and reduces stimulation of enzyme production. Administering antihypertensive medications (A) is not directly related to pancreatitis care. Placing the client in a supine position (C) may not be comfortable and can exacerbate pain. Monitoring for hypercalcemia (D) is important in chronic pancreatitis but not typically a priority in acute cases.
Medical History: Cerebrovascular accident (CVA) 2 years ago, Coronary artery disease, Hypertension, Hyperlipidemia. A nurse is reviewing the client's medical record. After reviewing the medical history, the nurse must determine which of the following actions to take.
For each potential provider’s prescription, the nurse must select if the action is Anticipated, Nonessential, or Contraindicated for the client.
- A. Encourage the client to cough
- B. Elevate the head of the bed
- C. Assist the client to the bathroom
- D. Decrease oxygen to 1.5 L/min via nasal cannula
- E. Keep the client’s head in a midline position
- F. Initiate seizure precautions
Correct Answer: B, A, C, A
Rationale: The correct answer is based on the rationale below:
1. Elevate the head of the bed (B): This action is Anticipated as it helps prevent aspiration and promotes optimal respiratory function.
2. Encourage the client to cough (A): Also Anticipated as coughing helps clear secretions and maintain airway patency.
3. Assist the client to the bathroom (C): This is Non-essential unless there are specific concerns about the client's mobility or urgency.
4. Decrease oxygen to 1.5 L/min via nasal cannula (A): Contraindicated as it may compromise oxygenation, especially without proper assessment and orders.
Other choices:
- Keeping the client's head in a midline position (E) is not provided in the question stem, so it cannot be evaluated.
- Initiating seizure precautions (F) is not relevant to the client's immediate care based on the information given
A nurse is planning care for an older adult client who has a history of dementia and is admitted following surgical repair of a hip fracture. Which of the following actions should the nurse plan to take?
- A. Encourage frequent visits from friends
- B. Apply restraints to the upper extremities
- C. Play serene soothing music
- D. Keep the over-the-bed light on
Correct Answer: C
Rationale: The correct answer is C: Play serene soothing music. Music therapy has been shown to be effective in reducing anxiety and agitation in individuals with dementia. Serene music can help create a calming environment, promoting relaxation and potentially improving the client's overall well-being. Encouraging visits from friends (Choice A) may overwhelm the client with dementia. Applying restraints to the upper extremities (Choice B) is not recommended as it can lead to physical and psychological harm. Keeping the over-the-bed light on (Choice D) may disrupt the client's sleep and exacerbate confusion.
A nurse is planning care for a client who has developed nephrotic syndrome. Which of the following dietary recommendations should the nurse include?
- A. Increase phosphorus intake
- B. Decrease carbohydrate intake
- C. Decrease protein intake
- D. Increase potassium intake
Correct Answer: C
Rationale: The correct answer is C: Decrease protein intake. Nephrotic syndrome causes protein loss through urine, leading to hypoalbuminemia and edema. Decreasing protein intake can help reduce proteinuria and decrease the workload on the kidneys. Increasing phosphorus intake (A) can worsen kidney function. Decreasing carbohydrate intake (B) is not directly related to managing nephrotic syndrome. Increasing potassium intake (D) is not recommended as it can lead to hyperkalemia in individuals with kidney issues.