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The client diagnosed with an acute exacerbation of SLE is prescribed high-dose steroids. Which statement best explains the scientific rationale for using high-dose steroids in treating SLE?
- A. The steroids will increase the body's ability to fight the infection.
- B. The steroids will decrease the chance of the SLE spreading to other organs.
- C. The steroids will suppress tissue inflammation, which reduces damage to organs.
- D. The steroids will prevent scarring of skin tissues associated with SLE.
Correct Answer: C
Rationale: Steroids suppress inflammation in SLE, reducing organ damage. They do not fight infection, prevent disease spread, or address skin scarring primarily.
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Which discharge instruction should the nurse implement for the client newly diagnosed with myasthenia gravis (MG)?
- A. Identify specific measures to help avoid fatigue and undue stress.
- B. Instruct the client to pad bony prominences, especially the sacral area.
- C. Discuss complementary therapies to help manage pain.
- D. Explain the possibility of having a splenectomy to help control the symptoms.
Correct Answer: A
Rationale: Avoiding fatigue and stress prevents myasthenia gravis exacerbations. Padding, pain therapies, and splenectomy are irrelevant.
The client with multiple sclerosis is prescribed the muscle relaxant baclofen (Lioresal). Which statement by the client indicates the client needs more teaching?
- A. This medication may cause drowsiness so I need to be careful.
- B. I should not drink any type of alcohol or take any antihistamines.
- C. I will increase the fiber in my diet and increase fluid intake.
- D. I stopped taking the medication because I can't afford it.
Correct Answer: D
Rationale: Stopping baclofen due to cost risks symptom worsening, indicating a need for teaching on adherence. Drowsiness, alcohol avoidance, and fiber/fluid intake are correct.
The charge nurse observes the primary nurse interacting with a client. Which action by the primary nurse warrants immediate intervention by the charge nurse?
- A. The nurse explains the IVP diuretic will make the client urinate.
- B. The nurse dons nonsterile gloves to remove the client's dressing.
- C. The nurse administers a medication without checking for allergies.
- D. The nurse asks the UAP for help moving a client up in bed.
Correct Answer: C
Rationale: Administering medication without checking allergies risks allergic reactions, requiring immediate intervention. Diuretic explanation, glove use, and UAP assistance are appropriate.
The client in the HCP's office is complaining of allergic rhinitis. Which assessment question is important for the nurse to ask the client?
- A. What time of year do the symptoms occur?
- B. Which over-the-counter medications have you tried?
- C. Do other members of your family have allergies to animals?
- D. Why do you think you have allergies?
Correct Answer: A
Rationale: Seasonal patterns help identify allergic rhinitis triggers. Medications, family history, and client beliefs are secondary.
The nurse is caring for a client with suspected fibromyalgia. Which diagnostic test confirms the diagnosis of fibromyalgia?
- A. There is no diagnostic test to confirm fibromyalgia.
- B. A positive antinuclear antibody test.
- C. A magnetic resonance imaging (MRI) shows fibrosis.
- D. A negative erythrocyte sedimentation rate (ESR).
Correct Answer: A
Rationale: Fibromyalgia is diagnosed clinically, with no confirmatory test. ANA, MRI, and ESR are not diagnostic.