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.
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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.
The nurse on a medical unit has received the morning shift report. Which client should the nurse assess first?
- A. The client who has a 0730 sliding-scale insulin order.
- B. The client who received an initial dose of IV antibiotic at 0645.
- C. The client who is having back pain at a '4' on a 1-to-10 scale.
- D. The client who has dysphagia and needs to be fed.
Correct Answer: A
Rationale: The 0730 insulin order is time-sensitive to prevent hyperglycemia or hypoglycemia. Antibiotic monitoring, mild pain, and dysphagia are less urgent.
The concept of impaired immunity has been identified by the nurse as it applies to the client diagnosed with Acquired Immune Deficiency Syndrome (AIDS). Which interventions should the nurse implement?
- A. Keep fresh flowers and raw vegetables out of the client's room.
- B. Have the Unlicensed Assistive Personnel (UAP) assist with ADLs.
- C. Encourage the client to perform active range of motion.
- D. Teach the client about the cardiovascular medications.
Correct Answer: A
Rationale: Avoiding flowers and raw vegetables reduces infection risk in AIDS. UAP assistance, ROM, and cardiovascular teaching are unrelated to immunity.
The client diagnosed with an acute exacerbation of multiple sclerosis is placed on high-dose intravenous injections of corticosteroid medication. Which nursing intervention should be implemented?
- A. Discuss discontinuing the proton pump inhibitor with the HCP.
- B. Hold the medication until after all cultures have been obtained.
- C. Monitor the client's serum blood glucose levels frequently.
- D. Provide supplemental dietary sodium with the client's meals.
Correct Answer: C
Rationale: High-dose corticosteroids can cause hyperglycemia, requiring frequent glucose monitoring. Proton pump inhibitors are unrelated, cultures are not needed, and sodium supplementation is unnecessary.
The nurse is planning the care for a client diagnosed with RA. Which intervention should be implemented?
- A. Plan a strenuous exercise program.
- B. Order a mechanical soft diet.
- C. Maintain a keep-open IV.
- D. Obtain an order for a sedative.
Correct Answer: C
Rationale: A keep-open IV ensures access for RA medications (e.g., biologics). Strenuous exercise worsens joints, soft diets are unrelated, and sedatives are not routine.