Nokea
The client with myasthenia gravis is undergoing plasmapheresis at the bedside. Which assessment data warrant immediate intervention?
- A. The client's BP is 94/60 and AP is 112.
- B. Negative Chvostek's and Trousseau's signs.
- C. The serum potassium level is 3.5 mEq/L.
- D. Ecchymosis at the vascular site access.
Correct Answer: A
Rationale: Hypotension (BP 94/60) and tachycardia (AP 112) during plasmapheresis suggest hypovolemia or reaction, requiring immediate intervention. Negative signs, normal potassium, and ecchymosis are less urgent.
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The client newly diagnosed with multiple sclerosis (MS) states, 'I don't understand how I got multiple sclerosis. Is it genetic?' On which statement should the nurse base the response?
- A. Genetics may play a role in susceptibility to MS, but the disease may be caused by a virus.
- B. There is no evidence suggesting there is any chromosomal involvement in developing MS.
- C. Multiple sclerosis is caused by a recessive gene, so both parents had to have the gene for the client to get MS.
- D. Multiple sclerosis is caused by an autosomal dominant gene on the Y chromosome, so only fathers can pass it on.
Correct Answer: A
Rationale: MS has a genetic susceptibility component (e.g., HLA genes), but environmental factors like viral infections may trigger it. There is chromosomal involvement, MS is not purely recessive or dominant, and it is not Y-linked.
The concept of impaired immunity has been identified by the nurse as it applies to the client diagnosed with Acquired Immune Deficiency Syndrome (AIDS). Which interventions should the nurse implement?
- A. Keep fresh flowers and raw vegetables out of the client's room.
- B. Have the Unlicensed Assistive Personnel (UAP) assist with ADLs.
- C. Encourage the client to perform active range of motion.
- D. Teach the client about the cardiovascular medications.
Correct Answer: A
Rationale: Avoiding flowers and raw vegetables reduces infection risk in AIDS. UAP assistance, ROM, and cardiovascular teaching are unrelated to immunity.
Which intervention is an important psychosocial consideration for the client diagnosed with AIDS?
- A. Perform a thorough head-to-toe assessment.
- B. Maintain the client's ideal body weight.
- C. Complete an advance directive.
- D. Increase the client's activity tolerance.
Correct Answer: C
Rationale: Completing an advance directive addresses end-of-life wishes, a key psychosocial need in AIDS. Assessment, weight, and activity are physiological.
The nurse caring for the client diagnosed with Guillain-Barré syndrome writes the client problem 'impaired physical mobility.' Which long-term goal should be written for this problem?
- A. The client will have no skin irritation.
- B. The client will have no muscle atrophy.
- C. The client will perform range-of-motion exercises.
- D. The client will turn every two (2) hours while awake.
Correct Answer: C
Rationale: Performing range-of-motion exercises is a measurable long-term goal to improve mobility. Skin irritation, atrophy prevention, and turning are interventions, not goals.
The client recently diagnosed with SLE asks the nurse, 'What is SLE and how did I get it?' Which statement best explains the scientific rationale for the nurse's response?
- A. SLE occurs because the kidneys do not filter antibodies from the blood.
- B. SLE occurs after a viral illness as a result of damage to the endocrine system.
- C. There is no known identifiable reason for a client to develop SLE.
- D. This is an autoimmune disease that may have a genetic or hormonal component.
Correct Answer: D
Rationale: SLE is an autoimmune disease with genetic and hormonal influences. Kidney issues are a complication, viral triggers are secondary, and the cause is partially understood.