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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.
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The client is diagnosed with Multi Organ Dysfunction Syndrome (MODS). Which is the most appropriate goal for the nurse to write when planning the client's care?
- A. The client will maintain vital signs within normal limits during the next 24 hours.
- B. The client's urine output will be maintained to achieve output of 600 mL in the next 24 hours.
- C. The client will have elevated ALT, AST, and GGT liver enzymes within the next 24 hours.
- D. The client's blood glucose reading will be 200 to 240 mg/dL for the next 24 hours.
Correct Answer: A
Rationale: Maintaining normal vital signs is a broad, achievable goal in MODS. Urine output is specific, elevated enzymes are undesirable, and high glucose is not a goal.
Which sign/symptom should the nurse expect to assess in the client who is in the recovery stage of Guillain-Barré syndrome?
- A. Decreasing deep tendon reflexes.
- B. Drooping of the eyelids has resolved.
- C. A positive Babinski's reflex.
- D. Descending increase in muscle strength.
Correct Answer: D
Rationale: Recovery in Guillain-Barré syndrome shows descending muscle strength improvement. Reflexes improve, ptosis is unrelated, and Babinski’s is not typical.
The nurse is admitting a client diagnosed with R/O SLE. Which assessment data observed by the nurse support the diagnosis of SLE?
- A. Pericardial friction rub and crackles in the lungs.
- B. Muscle spasticity and bradykinesia.
- C. Hirsutism and clubbing of the fingers.
- D. Somnolence and weight gain.
Correct Answer: A
Rationale: Pericardial friction rub and lung crackles indicate serositis, common in SLE. Spasticity, hirsutism, and somnolence suggest other conditions.
Which type of isolation technique is designed to decrease the risk of transmission of recognized and unrecognized sources of infections?
- A. Contact Precautions.
- B. Airborne Precautions.
- C. Droplet Precautions.
- D. Standard Precautions.
Correct Answer: D
Rationale: Standard Precautions reduce transmission of all infections by assuming all patients are infectious. Contact, airborne, and droplet precautions are for specific transmission modes.
The client with acquired immunodeficiency syndrome (AIDS) dementia is referred to hospice. Which intervention has highest priority when caring for the client in the home?
- A. Assess the client's social support network.
- B. Identify the client's usual coping methods.
- C. Have consistent uninterrupted time with the client.
- D. Discuss and complete an advance directive.
Correct Answer: D
Rationale: Completing an advance directive ensures end-of-life wishes are honored, a priority in hospice. Support, coping, and time are secondary.