Nokea
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.
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The nurse enters the room of a client diagnosed with acute exacerbation of multiple sclerosis and finds the client crying. Which statement is the most therapeutic response for the nurse to make?
- A. Why are you crying? The medication will help the disease.
- B. You seem upset. I will sit down and we can talk for awhile.
- C. Multiple sclerosis is a disease that has good times and bad times.
- D. I will have the chaplain come and stay with you for a while.
Correct Answer: B
Rationale: Acknowledging the client’s distress and offering to talk is therapeutic, fostering emotional support. 'Why' questions are confrontational, disease facts dismiss feelings, and chaplain referral is premature.
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 nurse is preparing to administer morning medications. Which medication should the nurse administer first?
- A. The pain medication to a client diagnosed with RA.
- B. The diuretic medication to a client diagnosed with SLE.
- C. The steroid to a client diagnosed with polymyositis.
- D. The appetite stimulant to a client diagnosed with OA.
Correct Answer: C
Rationale: Steroids for polymyositis address inflammation and muscle weakness, a priority in autoimmune disease. Pain, diuresis, and appetite are less urgent.
The nurse is caring for clients on a medical floor. Which client should be assessed first?
- A. The client diagnosed with SLE who is complaining of chest pain.
- B. The client diagnosed with MS who is complaining of pain at a '10.'
- C. The client diagnosed with myasthenia gravis who has dysphagia.
- D. The client diagnosed with GB syndrome who can barely move his toes.
Correct Answer: A
Rationale: Chest pain in SLE may indicate pericarditis or pleuritis, potentially life-threatening, requiring immediate assessment. Severe pain, dysphagia, and toe weakness are less acute.
The client diagnosed with myasthenia gravis is being discharged home. Which intervention has priority when teaching the client's significant others?
- A. Discuss ways to help prevent choking episodes.
- B. Explain how to care for a client on a ventilator.
- C. Teach how to perform passive range-of-motion exercises.
- D. Demonstrate how to care for the client's feeding tube.
Correct Answer: A
Rationale: Preventing choking is critical due to dysphagia in myasthenia gravis. Ventilator care, ROM, and feeding tubes are less common or secondary.