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.
You may also like to solve these questions
The client diagnosed with AIDS is angry and yells at everyone entering the room, and none of the staff members wants to care for the client. Which intervention is most appropriate for the nurse manager to use in resolving this situation?
- A. Assign a different nurse every shift to the client.
- B. Ask the HCP to tell the client not to yell at the staff.
- C. Call a team meeting and discuss options with the staff.
- D. Tell one (1) staff member to care for the client a week at a time.
Correct Answer: C
Rationale: A team meeting fosters collaboration to address the client’s behavior and staff concerns. Rotating nurses, HCP intervention, or single-nurse assignment are less effective.
The client diagnosed with myasthenia gravis is admitted to the emergency department with a sudden exacerbation of motor weakness. Which assessment data indicate the client is experiencing a cholinergic crisis?
- A. The serum assay of circulating acetylcholine receptor antibodies is increased.
- B. The client's symptoms improve when administering a cholinesterase inhibitor.
- C. The client's blood pressure, pulse, and respirations improve after IV fluid.
- D. The Tensilon test does not show improvement in the client's muscle strength.
Correct Answer: D
Rationale: Cholinergic crisis (overdose of cholinesterase inhibitors) shows no improvement with Tensilon, unlike myasthenic crisis. Antibody levels, symptom improvement, and vital signs are not specific.
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 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.
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.