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The client diagnosed with myasthenia gravis is admitted with an acute exacerbation. Which interventions should the nurse implement? Select all that apply.
- A. Assist the client to turn and cough every two (2) hours.
- B. Place the client in a high or semi-Fowler's position.
- C. Assess the client's pulse oximeter reading every shift.
- D. Plan meals to promote medication effectiveness.
- E. Monitor the client's serum anticholinesterase levels.
Correct Answer: A,B,C,D
Rationale: Turning/coughing, Fowler’s position, pulse oximetry, and meal timing address respiratory risk and medication efficacy in myasthenia gravis. Serum anticholinesterase levels are not routinely monitored.
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The nurse is caring for the client diagnosed with acquired immunodeficiency syndrome (AIDS) dementia. Which action by the unlicensed assistive personnel (UAP) requires immediate intervention by the nurse?
- A. The UAP is helping the client to sit on the bedside chair.
- B. The UAP is wearing sterile gloves when bathing the client.
- C. The UAP is helping the client shave and brush the teeth.
- D. The UAP is providing a back massage to the client.
Correct Answer: B
Rationale: Sterile gloves are unnecessary for bathing, risking improper technique. Sitting, shaving, and massage are appropriate UAP tasks.
The nurse is caring for clients on a medical floor. Which client should the nurse assess first?
- A. The client diagnosed with RA complaining of pain at a '3' on a 1-to-10 scale.
- B. The client diagnosed with SLE who has a rash across the bridge of the nose.
- C. The client diagnosed with advanced RA who is receiving antineoplastic drugs IV.
- D. The client diagnosed with scleroderma who has hard, waxlike skin near the eyes.
Correct Answer: C
Rationale: Antineoplastic drugs (e.g., methotrexate) pose risks like toxicity, requiring immediate assessment. Mild pain, rashes, and scleroderma are less acute.
The school nurse is preparing to teach a health class to ninth graders regarding sexually transmitted diseases. Which information regarding acquired immunodeficiency syndrome (AIDS) should be included?
- A. Females taking birth control pills are protected from becoming infected with HIV.
- B. Protected sex is no longer an issue because there is a vaccine for the HIV virus.
- C. Adolescents with a normal immune system are not at risk for developing AIDS.
- D. Abstinence is the only guarantee of not becoming infected with sexually transmitted HIV.
Correct Answer: D
Rationale: Abstinence is the only certain way to prevent sexually transmitted HIV. Birth control pills, vaccines, and immune status do not eliminate risk.
The client admitted with rule-out Guillain-Barré syndrome has just had a lumbar puncture. Which intervention should the nurse implement postprocedure?
- A. Monitor the client for hypotension.
- B. Apply pressure to the puncture site.
- C. Test the client's cerebrospinal fluid.
- D. Increase the client's fluid intake.
Correct Answer: D
Rationale: Increasing fluid intake post-lumbar puncture prevents spinal headache. Hypotension is not a primary concern, pressure is applied during the procedure, and CSF testing is lab-based.
Which referral should the nurse implement for a client with severe multiple allergies?
- A. Registered dietitian.
- B. Occupational therapist.
- C. Recreational therapist.
- D. Social worker.
Correct Answer: A
Rationale: A dietitian helps identify food allergens, critical for severe allergies. Other therapists are less relevant.