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The client in the HCP's office has a red, raised rash covering the forearms, neck, and face and is experiencing extreme itching which is diagnosed as an allergic reaction to poison ivy. Which discharge instructions should the nurse teach?
- A. Tell the client never to scratch the rash.
- B. Instruct the client in administering IM Benadryl.
- C. Explain how to take a steroid dose pack.
- D. Have the client wear shirts with long sleeves and high necks.
Correct Answer: C
Rationale: A steroid dose pack reduces inflammation and itching in poison ivy reactions. Never scratching is unrealistic, IM Benadryl is HCP-administered, and clothing is preventive.
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The client diagnosed with multiple sclerosis is having trouble maintaining balance. Which intervention should the nurse discuss with the client?
- A. Discuss obtaining a motorized wheelchair for the client.
- B. Teach the client to stand with the feet slightly apart.
- C. Encourage the client to narrow his or her base of support.
- D. Explain the need to balance activity with rest.
Correct Answer: B
Rationale: Standing with feet apart widens the base of support, improving balance in MS. Wheelchairs are premature, narrowing support worsens balance, and rest is secondary.
The client is prescribed a prick epicutaneous test to determine the cause of hypersensitivity reactions. Which result indicates the client is hypersensitive to the allergen?
- A. The client complains of shortness of breath.
- B. The skin is dry, intact, and without redness.
- C. The pricked blood tests positive for allergens.
- D. A pruritic wheal and erythema occur.
Correct Answer: D
Rationale: A pruritic wheal and erythema at the prick site indicate a positive allergic response. Shortness of breath is systemic, dry skin is negative, and blood tests are separate.
The health-care provider scheduled a lumbar puncture for a client admitted with rule-out Guillain-Barré syndrome. Which preprocedure intervention has priority?
- A. Keep the client NPO.
- B. Instruct the client to void.
- C. Place in the lithotomy position.
- D. Assess the client's pedal pulse.
Correct Answer: B
Rationale: Voiding before a lumbar puncture prevents discomfort and reduces complications. NPO is unnecessary, lithotomy is incorrect, and pedal pulse is irrelevant.
The nurse is caring for clients on a medical floor. Which client should be assessed first?
- A. The client diagnosed with SLE who is complaining of chest pain.
- B. The client diagnosed with MS who is complaining of pain at a '10.'
- C. The client diagnosed with myasthenia gravis who has dysphagia.
- D. The client diagnosed with GB syndrome who can barely move his toes.
Correct Answer: A
Rationale: Chest pain in SLE may indicate pericarditis or pleuritis, potentially life-threatening, requiring immediate assessment. Severe pain, dysphagia, and toe weakness are less acute.
The client on a medical floor is diagnosed with HIV encephalopathy. Which client problem is priority?
- A. Altered nutrition, less than body requirements.
- B. Anticipatory grieving.
- C. Knowledge deficit, procedures and prognosis.
- D. Risk for injury.
Correct Answer: D
Rationale: HIV encephalopathy increases confusion and motor deficits, making risk for injury the priority. Nutrition, grieving, and knowledge are secondary.