Nokea
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.
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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 client diagnosed with myasthenia gravis is being discharged home. Which intervention has priority when teaching the client's significant others?
- A. Discuss ways to help prevent choking episodes.
- B. Explain how to care for a client on a ventilator.
- C. Teach how to perform passive range-of-motion exercises.
- D. Demonstrate how to care for the client's feeding tube.
Correct Answer: A
Rationale: Preventing choking is critical due to dysphagia in myasthenia gravis. Ventilator care, ROM, and feeding tubes are less common or secondary.
The nurse enters the room of a client diagnosed with acute exacerbation of multiple sclerosis and finds the client crying. Which statement is the most therapeutic response for the nurse to make?
- A. Why are you crying? The medication will help the disease.
- B. You seem upset. I will sit down and we can talk for awhile.
- C. Multiple sclerosis is a disease that has good times and bad times.
- D. I will have the chaplain come and stay with you for a while.
Correct Answer: B
Rationale: Acknowledging the client’s distress and offering to talk is therapeutic, fostering emotional support. 'Why' questions are confrontational, disease facts dismiss feelings, and chaplain referral is premature.
The client is diagnosed with myasthenia gravis. Which intervention should the nurse implement when administering the anticholinesterase pyridostigmine (Mestinon)?
- A. Administer the medication 30 minutes prior to meals.
- B. Instruct the client to take with eight (8) ounces of water.
- C. Explain the importance of sitting up for one (1) hour after taking medication.
- D. Assess the client's blood pressure prior to administering medication.
Correct Answer: A
Rationale: Administering pyridostigmine 30 minutes before meals maximizes muscle strength for swallowing. Water volume, sitting up, and BP checks are not specific requirements.
The client diagnosed with Guillain-Barré syndrome asks the nurse, 'Will I ever get back to normal? I am so tired of being sick.' Which statement is the best response by the nurse?
- A. You should make a full recovery within a few months to a year.
- B. Most clients with this syndrome have some type of residual disability.
- C. This is something you should discuss with the health-care team.
- D. The rehabilitation is short and you should be fully recovered within a month.
Correct Answer: A
Rationale: Most clients with Guillain-Barré syndrome recover fully within months to a year. Residual disability is less common, deferring to the team avoids education, and one-month recovery is unrealistic.