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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.
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The nurse is admitting a client diagnosed with protein-calorie malnutrition secondary to AIDS. Which intervention should be the nurse's first intervention?
- A. Assess the client's body weight and ask what the client has been able to eat.
- B. Place in contact isolation and don a mask and gown before entering the room.
- C. Check the HCP's orders and determine what laboratory tests will be done.
- D. Teach the client about total parenteral nutrition and monitor the subclavian IV site.
Correct Answer: A
Rationale: Assessing weight and dietary intake provides baseline data for malnutrition management. Isolation is unnecessary, lab orders are secondary, and TPN teaching is premature.
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.
Which intervention has the highest priority when caring for a client diagnosed with rheumatoid arthritis?
- A. Encourage the client to ventilate feelings about the disease process.
- B. Discuss the effects of disease on the client's career and other life roles.
- C. Instruct the client to perform most important activities in the morning.
- D. Teach the client the proper use of hot and cold therapy to provide pain relief.
Correct Answer: D
Rationale: Hot and cold therapy directly relieves RA pain, a priority. Emotional ventilation, career impact, and morning activity are secondary.
The nurse caring for the client diagnosed with Guillain-Barré syndrome writes the client problem 'impaired physical mobility.' Which long-term goal should be written for this problem?
- A. The client will have no skin irritation.
- B. The client will have no muscle atrophy.
- C. The client will perform range-of-motion exercises.
- D. The client will turn every two (2) hours while awake.
Correct Answer: C
Rationale: Performing range-of-motion exercises is a measurable long-term goal to improve mobility. Skin irritation, atrophy prevention, and turning are interventions, not goals.
The client diagnosed with an anaphylactic reaction is admitted to the emergency department. Which assessment data indicate the client is not responding to the treatment?
- A. The client has a urinary output of 120 mL in two (2) hours.
- B. The client has an AP of 110 and a BP of 90/60.
- C. The client has clear breath sounds and an RR of 26.
- D. The client has hyperactive bowel sounds.
Correct Answer: B
Rationale: Hypotension (BP 90/60) and tachycardia (AP 110) indicate ongoing anaphylaxis despite treatment. Normal urine output, clear lungs, and bowel sounds suggest improvement.