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 anaphylactic reaction is admitted to the emergency department. Which assessment data indicate the client is not responding to the treatment?
- A. The client has a urinary output of 120 mL in two (2) hours.
- B. The client has an AP of 110 and a BP of 90/60.
- C. The client has clear breath sounds and an RR of 26.
- D. The client has hyperactive bowel sounds.
Correct Answer: B
Rationale: Hypotension (BP 90/60) and tachycardia (AP 110) indicate ongoing anaphylaxis despite treatment. Normal urine output, clear lungs, and bowel sounds suggest improvement.
The primary nurse is administering medications to the assigned clients. Which client situation requires immediate intervention by the charge nurse?
- A. The client with congestive heart failure with an apical pulse of 64 who received 0.125 mg digoxin, a cardiac glycoside.
- B. The client with essential hypertension who received a beta blocker and has a blood pressure of 114/80.
- C. The client with myasthenia gravis who received the anticholinesterase medication 30 minutes late.
- D. The client with AIDS who received trimethoprim-sulfamethoxazole, an antibiotic, and has a CD4 cell count of less than 200.
Correct Answer: C
Rationale: A 30-minute delay in anticholinesterase for myasthenia gravis risks muscle weakness exacerbation, requiring intervention. Digoxin, beta blocker, and antibiotic administration are appropriate.
The nurse caring for the client diagnosed with Guillain-Barré syndrome writes the client problem 'impaired physical mobility.' Which long-term goal should be written for this problem?
- A. The client will have no skin irritation.
- B. The client will have no muscle atrophy.
- C. The client will perform range-of-motion exercises.
- D. The client will turn every two (2) hours while awake.
Correct Answer: C
Rationale: Performing range-of-motion exercises is a measurable long-term goal to improve mobility. Skin irritation, atrophy prevention, and turning are interventions, not goals.
The client recently diagnosed with rheumatoid arthritis is prescribed aspirin, a nonsteroidal anti-inflammatory medication. Which comment by the client warrants immediate intervention by the nurse?
- A. I always take the aspirin with food.
- B. If I have dark stools, I will call my HCP.
- C. Aspirin will not cure my arthritis.
- D. I am having some ringing in my ears.
Correct Answer: D
Rationale: Ringing in the ears (tinnitus) indicates aspirin toxicity, requiring immediate intervention. Taking with food, reporting dark stools, and understanding no cure are correct.
The 45-year-old client is diagnosed with primary progressive multiple sclerosis and the nurse writes the nursing diagnosis 'anticipatory grieving related to progressive loss.' Which intervention should be implemented first?
- A. Consult the physical therapist for assistive devices for mobility.
- B. Determine if the client has a legal power of attorney.
- C. Ask if the client would like to talk to the hospital chaplain.
- D. Discuss the client's wishes regarding end-of-life care.
Correct Answer: C
Rationale: Addressing anticipatory grieving involves exploring spiritual or emotional support, like a chaplain visit. Mobility devices, legal documents, and end-of-life discussions are secondary.