Nokea
The client has had an anaphylactic reaction to insect venom, a bee sting. Which discharge instruction should the nurse discuss with the client?
- A. Take a corticosteroid dose pack when stung by a bee.
- B. Take antihistamines prior to outdoor activities.
- C. Use a cromolyn sodium (Intal) inhaler prophylactically.
- D. Carry a bee sting kit, especially when going outside.
Correct Answer: D
Rationale: Carrying a bee sting kit (EpiPen) is critical for managing future anaphylaxis. Steroids, antihistamines, and cromolyn are less effective prophylactically.
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The nurse writes the client problem of 'altered sexual functioning' for a male client diagnosed with multiple sclerosis (MS). Which intervention should be implemented?
- A. Encourage the couple to explore alternative ways of maintaining intimacy.
- B. Make an appointment with a psychotherapist to counsel the couple.
- C. Explain daily exercise will help increase libido and sexual arousal.
- D. Discuss the importance of keeping physically calm during sexual intercourse.
Correct Answer: A
Rationale: Exploring alternative intimacy methods addresses MS-related sexual dysfunction holistically. Psychotherapy is secondary, exercise may not improve libido, and physical calm is vague.
Which statement by the female client diagnosed with myasthenia gravis indicates the client needs more discharge teaching?
- A. I will not have any menstrual cycles because of this disease.
- B. I should avoid people who have respiratory infections.
- C. I should not take a hot bath or swim in cold water.
- D. I will drink at least 2,500 mL of water a day.
Correct Answer: A
Rationale: Myasthenia gravis does not affect menstrual cycles, indicating a need for teaching. Avoiding infections, temperature extremes, and hydration are correct.
The nurse on a medical floor is caring for clients diagnosed with AIDS. Which client should be seen first?
- A. The client who has flushed, warm skin with tented turgor.
- B. The client who states the staff ignores the call light.
- C. The client whose vital signs are T 99.9°F, P 101, R 26, and BP 110/68.
- D. The client who is unable to provide a sputum specimen.
Correct Answer: C
Rationale: Fever, tachycardia, and tachypnea suggest infection or sepsis, requiring immediate assessment. Dehydration, call light complaints, and sputum issues are less acute.
Which interventions should the nurse discuss with the female client who is positive for human immunodeficiency virus (HIV)? Select all that apply.
- A. Recommend the client not to engage in unprotected sexual activity.
- B. Instruct the client not to inform past sexual partners of HIV status.
- C. Tell the client to not donate blood, organs, or tissues.
- D. Suggest the client not get pregnant.
- E. Explain the client does not have to tell health-care personnel of HIV status.
Correct Answer: A,C,D
Rationale: Unprotected sex, blood/organ donation, and pregnancy risk HIV transmission or complications. Partner notification and informing healthcare personnel are recommended.
The client with myasthenia gravis is prescribed the cholinesterase inhibitor neostigmine (Prostigmin). Which data indicate the medication is effective?
- A. The client is able to feed self independently.
- B. The client is able to blink the eyes without tearing.
- C. The client denies any nausea or vomiting when eating.
- D. The client denies any pain when performing ROM exercises.
Correct Answer: A
Rationale: Independent feeding indicates improved muscle strength, the goal of neostigmine. Blinking, nausea, and pain are less directly related.