Nokea
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.
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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.
Which is the highest priority nursing intervention for the client who is having an anaphylactic reaction?
- A. Administer parenteral epinephrine, an adrenergic agonist.
- B. Prepare for immediate endotracheal intubation.
- C. Provide a calm assurance when caring for the client.
- D. Establish and maintain a patent airway.
Correct Answer: D
Rationale: Establishing a patent airway is the highest priority in anaphylaxis, per ABCs. Epinephrine, intubation, and reassurance follow.
The client with acquired immunodeficiency syndrome (AIDS) dementia is referred to hospice. Which intervention has highest priority when caring for the client in the home?
- A. Assess the client's social support network.
- B. Identify the client's usual coping methods.
- C. Have consistent uninterrupted time with the client.
- D. Discuss and complete an advance directive.
Correct Answer: D
Rationale: Completing an advance directive ensures end-of-life wishes are honored, a priority in hospice. Support, coping, and time are secondary.
The client is prescribed a prick epicutaneous test to determine the cause of hypersensitivity reactions. Which result indicates the client is hypersensitive to the allergen?
- A. The client complains of shortness of breath.
- B. The skin is dry, intact, and without redness.
- C. The pricked blood tests positive for allergens.
- D. A pruritic wheal and erythema occur.
Correct Answer: D
Rationale: A pruritic wheal and erythema at the prick site indicate a positive allergic response. Shortness of breath is systemic, dry skin is negative, and blood tests are separate.
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.