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The client comes to the emergency department complaining of dyspnea and wheezing after eating at a seafood restaurant. The client cannot speak and has a bluish color around the mouth. Which intervention should the nurse implement first?
- A. Initiate an IV with normal saline.
- B. Prepare to intubate the client.
- C. Administer oxygen at 100%.
- D. Ask the client about an iodine allergy.
Correct Answer: C
Rationale: Administering 100% oxygen addresses immediate hypoxia in anaphylaxis, per ABCs. IV fluids, intubation, and allergy history follow.
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The nurse is caring for clients on a medical floor. Which client should be assessed first?
- A. The client diagnosed with SLE who is complaining of chest pain.
- B. The client diagnosed with MS who is complaining of pain at a '10.'
- C. The client diagnosed with myasthenia gravis who has dysphagia.
- D. The client diagnosed with GB syndrome who can barely move his toes.
Correct Answer: A
Rationale: Chest pain in SLE may indicate pericarditis or pleuritis, potentially life-threatening, requiring immediate assessment. Severe pain, dysphagia, and toe weakness are less acute.
The nurse is preparing to administer morning medications. Which medication should the nurse administer first?
- A. The pain medication to a client diagnosed with RA.
- B. The diuretic medication to a client diagnosed with SLE.
- C. The steroid to a client diagnosed with polymyositis.
- D. The appetite stimulant to a client diagnosed with OA.
Correct Answer: C
Rationale: Steroids for polymyositis address inflammation and muscle weakness, a priority in autoimmune disease. Pain, diuresis, and appetite are less urgent.
The client diagnosed with AIDS is angry and yells at everyone entering the room, and none of the staff members wants to care for the client. Which intervention is most appropriate for the nurse manager to use in resolving this situation?
- A. Assign a different nurse every shift to the client.
- B. Ask the HCP to tell the client not to yell at the staff.
- C. Call a team meeting and discuss options with the staff.
- D. Tell one (1) staff member to care for the client a week at a time.
Correct Answer: C
Rationale: A team meeting fosters collaboration to address the client’s behavior and staff concerns. Rotating nurses, HCP intervention, or single-nurse assignment are less effective.
The client diagnosed with multiple sclerosis is having trouble maintaining balance. Which intervention should the nurse discuss with the client?
- A. Discuss obtaining a motorized wheelchair for the client.
- B. Teach the client to stand with the feet slightly apart.
- C. Encourage the client to narrow his or her base of support.
- D. Explain the need to balance activity with rest.
Correct Answer: B
Rationale: Standing with feet apart widens the base of support, improving balance in MS. Wheelchairs are premature, narrowing support worsens balance, and rest is secondary.
Which sign/symptom should the nurse expect to assess in the client who is in the recovery stage of Guillain-Barré syndrome?
- A. Decreasing deep tendon reflexes.
- B. Drooping of the eyelids has resolved.
- C. A positive Babinski's reflex.
- D. Descending increase in muscle strength.
Correct Answer: D
Rationale: Recovery in Guillain-Barré syndrome shows descending muscle strength improvement. Reflexes improve, ptosis is unrelated, and Babinski’s is not typical.