Nokea
The client with multiple sclerosis is prescribed the muscle relaxant baclofen (Lioresal). Which statement by the client indicates the client needs more teaching?
- A. This medication may cause drowsiness so I need to be careful.
- B. I should not drink any type of alcohol or take any antihistamines.
- C. I will increase the fiber in my diet and increase fluid intake.
- D. I stopped taking the medication because I can't afford it.
Correct Answer: D
Rationale: Stopping baclofen due to cost risks symptom worsening, indicating a need for teaching on adherence. Drowsiness, alcohol avoidance, and fiber/fluid intake are correct.
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The nurse is caring for a client with suspected fibromyalgia. Which diagnostic test confirms the diagnosis of fibromyalgia?
- A. There is no diagnostic test to confirm fibromyalgia.
- B. A positive antinuclear antibody test.
- C. A magnetic resonance imaging (MRI) shows fibrosis.
- D. A negative erythrocyte sedimentation rate (ESR).
Correct Answer: A
Rationale: Fibromyalgia is diagnosed clinically, with no confirmatory test. ANA, MRI, and ESR are not diagnostic.
The school nurse is preparing to teach a health class to ninth graders regarding sexually transmitted diseases. Which information regarding acquired immunodeficiency syndrome (AIDS) should be included?
- A. Females taking birth control pills are protected from becoming infected with HIV.
- B. Protected sex is no longer an issue because there is a vaccine for the HIV virus.
- C. Adolescents with a normal immune system are not at risk for developing AIDS.
- D. Abstinence is the only guarantee of not becoming infected with sexually transmitted HIV.
Correct Answer: D
Rationale: Abstinence is the only certain way to prevent sexually transmitted HIV. Birth control pills, vaccines, and immune status do not eliminate risk.
Which discharge instruction should the nurse implement for the client newly diagnosed with myasthenia gravis (MG)?
- A. Identify specific measures to help avoid fatigue and undue stress.
- B. Instruct the client to pad bony prominences, especially the sacral area.
- C. Discuss complementary therapies to help manage pain.
- D. Explain the possibility of having a splenectomy to help control the symptoms.
Correct Answer: A
Rationale: Avoiding fatigue and stress prevents myasthenia gravis exacerbations. Padding, pain therapies, and splenectomy are irrelevant.
The nurse is assessing a 48-year-old client diagnosed with multiple sclerosis. Which clinical manifestation warrants immediate intervention?
- A. The client has scanning speech and diplopia.
- B. The client has dysarthria and scotomas.
- C. The client has muscle weakness and spasticity.
- D. The client has a congested cough and dysphagia.
Correct Answer: D
Rationale: Congested cough and dysphagia indicate potential airway and swallowing issues, requiring immediate intervention to prevent aspiration or respiratory distress. Neurological symptoms like speech issues, diplopia, scotomas, weakness, and spasticity are expected in MS but less acute.
The client diagnosed with Multi Organ Dysfunction Syndrome (MODS) has renal, cardiovascular, and pulmonary dysfunction issues. Which statement by the nurse indicates an understanding of the client's prognosis?
- A. As long as the client is maintained on a ventilator, then the prognosis can be up to 60% recovery.
- B. The client will have less than a 2% potential for recovery from the MODS.
- C. When three or more body systems fail, the mortality rate can be 70% to 80%.
- D. More than one body system in failure reduces the recovery rate to 80% to 90%.
Correct Answer: C
Rationale: MODS with three or more organ failures has a 70–80% mortality rate. Ventilator use, 2% recovery, and 80–90% recovery are inaccurate.