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The client with early-stage RA is being discharged from the outpatient clinic. Which discharge instruction should the nurse teach regarding the use of nonsteroidal anti-inflammatory drugs (NSAIDs)?
- A. Take with an over-the-counter medication for the stomach.
- B. Drink a full glass of water with each pill.
- C. If a dose is missed, double the medication at the next dosing time.
- D. Avoid taking the NSAID on an empty stomach.
Correct Answer: D
Rationale: Taking NSAIDs with food prevents gastric irritation. OTC stomach meds are not routine, water volume is secondary, and doubling doses is dangerous.
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Which assessment intervention should the nurse implement specifically for the diagnosis of Guillain-Barré syndrome?
- A. Assess deep tendon reflexes.
- B. Complete a Glasgow Coma Scale.
- C. Check for Babinski's reflex.
- D. Take the client's vital signs.
Correct Answer: A
Rationale: Decreased deep tendon reflexes are a hallmark of Guillain-Barré syndrome due to peripheral nerve involvement. Glasgow Coma Scale, Babinski’s reflex, and vital signs are less specific.
The nurse on a medical floor is caring for clients diagnosed with AIDS. Which client should be seen first?
- A. The client who has flushed, warm skin with tented turgor.
- B. The client who states the staff ignores the call light.
- C. The client whose vital signs are T 99.9°F, P 101, R 26, and BP 110/68.
- D. The client who is unable to provide a sputum specimen.
Correct Answer: C
Rationale: Fever, tachycardia, and tachypnea suggest infection or sepsis, requiring immediate assessment. Dehydration, call light complaints, and sputum issues are less acute.
Which surgical procedure should the nurse anticipate the client with myasthenia gravis undergoing to help prevent the signs/symptoms of the disease process?
- A. There is no surgical option.
- B. A transsphenoidal hypophysectomy.
- C. A thymectomy.
- D. An adrenalectomy.
Correct Answer: C
Rationale: Thymectomy can reduce symptoms in myasthenia gravis by removing the thymus, often implicated in autoimmunity. Other surgeries are irrelevant.
Which statement by the female client diagnosed with myasthenia gravis indicates the client needs more discharge teaching?
- A. I will not have any menstrual cycles because of this disease.
- B. I should avoid people who have respiratory infections.
- C. I should not take a hot bath or swim in cold water.
- D. I will drink at least 2,500 mL of water a day.
Correct Answer: A
Rationale: Myasthenia gravis does not affect menstrual cycles, indicating a need for teaching. Avoiding infections, temperature extremes, and hydration are correct.
The nurse is assessing a client with cutaneous lupus erythematosus. Which intervention should be implemented?
- A. Use astringent lotion on the face and skin.
- B. Inspect the skin weekly for open areas or rashes.
- C. Dry the skin thoroughly by patting.
- D. Apply anti-itch medication between the toes.
Correct Answer: C
Rationale: Patting the skin dry prevents irritation in cutaneous lupus. Astringents worsen dryness, weekly inspections are too infrequent, and toe medication is irrelevant.