Nokea
The 45-year-old client is diagnosed with primary progressive multiple sclerosis and the nurse writes the nursing diagnosis 'anticipatory grieving related to progressive loss.' Which intervention should be implemented first?
- A. Consult the physical therapist for assistive devices for mobility.
- B. Determine if the client has a legal power of attorney.
- C. Ask if the client would like to talk to the hospital chaplain.
- D. Discuss the client's wishes regarding end-of-life care.
Correct Answer: C
Rationale: Addressing anticipatory grieving involves exploring spiritual or emotional support, like a chaplain visit. Mobility devices, legal documents, and end-of-life discussions are secondary.
You may also like to solve these questions
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.
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 diagnosed with Guillain-Barré syndrome is having difficulty breathing and is placed on a ventilator. Which situation warrants immediate intervention by the nurse?
- A. The ventilator rate is set at 14 breaths per minute.
- B. A manual resuscitation bag is at the client's bedside.
- C. The client's pulse oximeter reading is 85%.
- D. The ABG results are pH 7.4, PaO2 88, PaCO2 35, and HCO3 24.
Correct Answer: C
Rationale: A pulse oximeter reading of 85% indicates hypoxemia, requiring immediate intervention. Ventilator rate, resuscitation bag, and normal ABGs are appropriate.
The client asks the nurse, 'Which time of the year is allergic rhinitis least likely to occur?' Which statement is the nurse's best response?
- A. It is least likely to occur during the springtime.
- B. Allergic rhinitis is not likely to occur during the summer.
- C. It is least likely to occur in the early fall.
- D. Allergic rhinitis is least likely to occur in early winter.
Correct Answer: D
Rationale: Early winter has lower pollen levels, reducing allergic rhinitis. Spring, summer, and fall are peak seasons.
The client is being evaluated to rule out myasthenia gravis and being administered the Tensilon (edrophonium chloride) test. Which response to the test indicates the client has myasthenia gravis?
- A. The client has no apparent change in the assessment data.
- B. There is increased amplitude of electrical stimulation in the muscle.
- C. The circulating acetylcholine receptor antibodies are decreased.
- D. The client shows a marked improvement of muscle strength.
Correct Answer: D
Rationale: The Tensilon test improves muscle strength in myasthenia gravis by inhibiting acetylcholinesterase. No change, electrical stimulation, or antibody levels are not diagnostic.