Nokea
The client diagnosed with Systemic Response Inflammatory Syndrome (SIRS) asks the nurse what the diagnosis means. Which is the nurse's best response?
- A. SIRS is a localized response to major trauma that has occurred within the last three (3) months.
- B. SIRS is a syndrome of potential responses to illness that has an optimum prognosis.
- C. SIRS is a respiratory response to the client having had a myocardial infarction or pneumonia.
- D. SIRS is a systemic response to a variety of insults, including infection, ischemia, and injury.
Correct Answer: D
Rationale: SIRS is a systemic response to insults like infection or trauma. It is not localized, has variable prognosis, and is not solely respiratory.
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The client diagnosed with an acute exacerbation of multiple sclerosis is placed on high-dose intravenous injections of corticosteroid medication. Which nursing intervention should be implemented?
- A. Discuss discontinuing the proton pump inhibitor with the HCP.
- B. Hold the medication until after all cultures have been obtained.
- C. Monitor the client's serum blood glucose levels frequently.
- D. Provide supplemental dietary sodium with the client's meals.
Correct Answer: C
Rationale: High-dose corticosteroids can cause hyperglycemia, requiring frequent glucose monitoring. Proton pump inhibitors are unrelated, cultures are not needed, and sodium supplementation is unnecessary.
The client recently diagnosed with SLE asks the nurse, 'What is SLE and how did I get it?' Which statement best explains the scientific rationale for the nurse's response?
- A. SLE occurs because the kidneys do not filter antibodies from the blood.
- B. SLE occurs after a viral illness as a result of damage to the endocrine system.
- C. There is no known identifiable reason for a client to develop SLE.
- D. This is an autoimmune disease that may have a genetic or hormonal component.
Correct Answer: D
Rationale: SLE is an autoimmune disease with genetic and hormonal influences. Kidney issues are a complication, viral triggers are secondary, and the cause is partially understood.
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 client with myasthenia gravis is undergoing plasmapheresis at the bedside. Which assessment data warrant immediate intervention?
- A. The client's BP is 94/60 and AP is 112.
- B. Negative Chvostek's and Trousseau's signs.
- C. The serum potassium level is 3.5 mEq/L.
- D. Ecchymosis at the vascular site access.
Correct Answer: A
Rationale: Hypotension (BP 94/60) and tachycardia (AP 112) during plasmapheresis suggest hypovolemia or reaction, requiring immediate intervention. Negative signs, normal potassium, and ecchymosis are less urgent.
The client diagnosed with SLE is being discharged from the medical unit. Which discharge instructions are most important for the nurse to include? Select all that apply.
- A. Use a sunscreen of SPF 30 or greater when in the sunlight.
- B. Notify the HCP immediately when developing a low-grade fever.
- C. Some dyspnea is expected and does not need immediate attention.
- D. The hands and feet may change color if exposed to cold or heat.
- E. Explain the client can be cured with continued therapy.
Correct Answer: A,B,D
Rationale: Sunscreen, fever reporting, and Raynaud’s phenomenon awareness prevent SLE flares and complications. Dyspnea requires attention, and SLE is not curable.