Nokea
The client diagnosed with RA is being seen in the outpatient clinic. Which preventive care should the nurse include in the regularly scheduled clinic visits?
- A. Perform joint x-rays to determine progression of the disease.
- B. Send blood to the laboratory for an erythrocyte sedimentation rate.
- C. Recommend the flu and pneumonia vaccines.
- D. Assess the client for increasing joint involvement.
Correct Answer: C
Rationale: Flu and pneumonia vaccines prevent infections, critical in RA due to immunosuppression. X-rays, ESR, and joint assessments are diagnostic, not preventive.
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The nurse and a female unlicensed assistive personnel (UAP) are caring for a group of clients on a medical floor. Which action by the UAP warrants immediate intervention by the nurse?
- A. The UAP washes her hands before and after performing vital signs on a client.
- B. The UAP dons sterile gloves prior to removing an indwelling catheter from a client.
- C. The UAP raises the head of the bed to a high Fowler's position for a client about to eat.
- D. The UAP uses a fresh plastic bag to get ice for a client's water pitcher.
Correct Answer: B
Rationale: Sterile gloves are unnecessary for catheter removal, risking improper technique and infection. Handwashing, Fowler’s position, and ice bag use are appropriate.
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.
Which ocular or facial signs/symptoms should the nurse expect to assess for the client diagnosed with myasthenia gravis?
- A. Weakness and fatigue.
- B. Ptosis and diplopia.
- C. Breathlessness and dyspnea.
- D. Weight loss and dehydration.
Correct Answer: B
Rationale: Ptosis and diplopia are hallmark ocular symptoms of myasthenia gravis due to neuromuscular weakness. General weakness, respiratory issues, and weight loss are less specific.
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.
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.