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.
The client is highly allergic to insect venom and is prescribed venom immunotherapy. Which statement is the scientific rationale for this treatment?
- A. Immunotherapy is effective in preventing anaphylaxis following a future sting.
- B. Immunotherapy will prevent all future insect stings from harming the client.
- C. This therapy will cure the client from having any allergic reactions in the future.
- D. This therapy is experimental and should not be undertaken by the client.
Correct Answer: A
Rationale: Venom immunotherapy desensitizes the immune system, reducing anaphylaxis risk. It does not prevent stings, cure all allergies, or remain experimental.
The client diagnosed with AIDS is complaining of a sore mouth and tongue. When the nurse assesses the buccal mucosa, the nurse notes white, patchy lesions covering the hard and soft palates and the right inner cheek. Which interventions should the nurse implement?
- A. Teach the client to brush the teeth and patchy area with a soft-bristle toothbrush.
- B. Notify the HCP for an order for an antifungal swish-and-swallow medication.
- C. Have the client gargle with an antiseptic-based mouthwash several times a day.
- D. Determine what types of food the client has been eating for the last 24 hours.
Correct Answer: B
Rationale: White, patchy lesions suggest oral candidiasis, common in AIDS, requiring antifungal medication. Brushing may worsen lesions, antiseptic mouthwash is insufficient, and diet history is secondary.
The female client is homeless and pregnant. The client supports an IV drug habit by prostitution. Which data would be considered antecedents (risk factor) for becoming HIV positive? Select all that apply.
- A. The client is pregnant.
- B. The client is an intravenous drug abuser.
- C. The client has multiple sexual partners.
- D. The client does not have available health care.
- E. The client does not have adequate bathroom facilities.
- F. The client spends her money on nonessential items.
Correct Answer: B,C,D
Rationale: IV drug use, multiple sexual partners, and lack of healthcare increase HIV risk. Pregnancy, bathroom facilities, and spending are not direct risk factors.
The nurse caring for a client who is HIV positive is stuck with the stylet used to start an IV. Which intervention should the nurse implement first?
- A. Flush the skin with water and try to get the area to bleed.
- B. Notify the charge nurse and complete an incident report.
- C. Report to the employee health nurse for prophylactic medication.
- D. Follow up with the infection control nurse to have laboratory work done.
Correct Answer: A
Rationale: Flushing and inducing bleeding at the site immediately reduces viral load. Notification, prophylaxis, and lab work follow.