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The client diagnosed with Multiple Organ Dysfunction Syndrome (MODS) is admitted to the intensive care department. Which assessment data are most important for the nurse to collect/monitor?
- A. Lung sounds, heart sounds, and blood pressure.
- B. The client's psychological response to the illness.
- C. The client's family's expectations of the hospitalization.
- D. Amount of emesis, bile secretions, and mouth ulcers.
Correct Answer: A
Rationale: Lung sounds, heart sounds, and BP monitor respiratory, cardiac, and hemodynamic status, critical in MODS. Psychological, family, and GI data are secondary.
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The client who has engaged in needle-sharing activities has developed a flu-like illness. An HIV antibody test is negative. Which statement best describes the scientific rationale for this finding?
- A. The client is fortunate not to have contracted HIV from an infected needle.
- B. The client must be repeatedly exposed to HIV before becoming infected.
- C. The client may be in the primary infection phase of an HIV infection.
- D. The antibody test is negative because the client has a different flu virus.
Correct Answer: C
Rationale: A negative antibody test during flu-like symptoms may indicate the primary HIV infection phase, before seroconversion. Single exposure can infect, and flu viruses are unrelated.
The nurse enters the room of a female client diagnosed with SLE and finds the client crying. Which statement is the most therapeutic response?
- A. I know you are upset, but stress makes the SLE worse.
- B. Please explain to me why you are crying.
- C. I recommend going to an SLE support group.
- D. I see you are crying. We can talk if you would like.
Correct Answer: D
Rationale: Acknowledging crying and offering to talk is therapeutic, encouraging emotional expression. Linking stress to SLE, demanding explanations, or suggesting groups are less supportive.
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 wife of a client diagnosed with myasthenia gravis is crying and shares with the nurse she just doesn't know what to do. Which response is the best action by the nurse?
- A. Discuss the Myasthenia Foundation with the client's wife.
- B. Refer the client to a local myasthenia gravis support group.
- C. Ask the client's wife if she would like to talk to a counselor.
- D. Sit down and allow the wife to ventilate her feelings to the nurse.
Correct Answer: D
Rationale: Allowing the wife to ventilate feelings is therapeutic, addressing immediate emotional distress. Foundation discussion, support groups, and counseling are secondary.
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.