Nokea
The clinic nurse is caring for a client with an allergic disorder who has received the first sensitizing dose of a new drug. What nursing action is most important at this point?
- A. Assess the client for reduced urine output.
- B. Monitor the client for reactions.
- C. Assess the client for reduced appetite.
- D. Monitor the client for increased heart rate.
Correct Answer: B
Rationale: Monitoring the client for 30 minutes after desensitization injection is necessary to assess for allergic symptoms. Although it is important to ensure the client's comfort, it is not essential to assess the client for changes in urine output, appetite, or heart rate.
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A client comes to the clinic to see the physician, reporting, 'I think I ate something that I am allergic to.' What symptoms would be appropriate for the nurse to ask questions about?
- A. Nasal congestion and coughing
- B. Hives and itching
- C. Sneezing and runny nose
- D. Diarrhea and abdominal cramping
Correct Answer: D
Rationale: Clinical manifestations generally correlate with the manner in which the allergen enters the body. Inhaled allergens usually cause respiratory symptoms, including nasal congestion, runny nose, sneezing, coughing, dyspnea, and wheezing. Contactants cause skin reactions such as hives, which appear as vesicles filled with clear fluid surrounded by a margin of redness, rash, and localized itching. Cramping, vomiting, and diarrhea are associated with ingested food allergens. Allergic skin responses may also occur with allergies to foods.
A client sustained an injury in one eye during a basketball game after being hit with another player's elbow. The client reports now having difficulty with vision in the other eye too, although that eye was not hit by the elbow. What does the nurse understand this phenomenon to be known as?
- A. Cataracts
- B. Psychosomatic blindness
- C. Glaucoma
- D. Sympathetic uveitis
Correct Answer: D
Rationale: When a person experiences trauma followed by inflammation to the iris, ciliary body, and choroid layer of one eye, the vision in the untraumatized eye also becomes affected. The term for this phenomenon is sympathetic uveitis. Cataracts do not occur from trauma, they develop over time. Psychosomatic blindness does not relate to the client's visual disturbance because the client is not blind at this time. Glaucoma is an eye disorder that occurs over time and is not related to trauma to the eye.
A client is taking oral corticosteroids after having an exacerbation of asthma. What should the nurse be sure to include when instructing the client how to take the medication?
- A. The medication will cause weight loss.
- B. The medication will cause drowsiness so do not drive.
- C. Take the medication on an empty stomach to increase absorption.
- D. Take the medication in the morning with food.
Correct Answer: D
Rationale: Taking the oral corticosteroids in the morning with food will help reduce the gastrointestinal upset that may be experienced. The medication causes weight gain not weight loss, does not cause drowsiness, and should not be taken on an empty stomach.
The nurse is instructing a client with chronic fatigue syndrome about what type of dietary sources are the best to eat to supply eicosapentaenoic acid (EPA). What statement by the client demonstrates the instruction is understood?
- A. I will eat shrimp at least twice a week.'
- B. I love crab cakes and will be sure to make them once a week.'
- C. Fresh salmon is one of my favorites, and I will eat it twice a week.'
- D. Lobster is expensive, but I will eat it once a week.'
Correct Answer: C
Rationale: Fish oils provide the only dietary source of EPA. Fatty fish, such as mackerel, sardines, herring, salmon, and tuna, are the best sources. Shellfish, such as shrimp, crab, and lobsters do not offer the dietary source of EPA that is required.
A client is taking a corticosteroid for the treatment of systemic lupus erythematosus. When the nurse is providing instructions about the medication to the client, what priority information should be included?
- A. If the client experiences nausea, omit the dose.
- B. The client should be alert for joint aches.
- C. This medication is commonly used for many inflammatory reactions and is relatively safe.
- D. Be alert for signs and symptoms of infection and report them immediately to the physician.
Correct Answer: D
Rationale: Instruct the client about signs and symptoms of and the increased risk for infection. Instruct the client to report signs and symptoms of infection immediately to the physician. Early treatment promotes a shorter duration of illness and reduced complication. Tell the client to avoid high-risk activities, such as being in crowds, during periods of immunosuppression. The client should not omit a dose if nausea is experienced but instead may take the medication with food. There are many side effects and required laboratory work to detect the side effects from immunosuppressive therapy. Joint aches are vague symptoms and are not a priority for reporting purposes.