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The home health nurse is caring for the client newly diagnosed with multiple sclerosis. Which client issue is of most importance?
- A. The client refuses to have a gastrostomy feeding.
- B. The client wants to discuss if she should tell her fiancé.
- C. The client tells the nurse life is not worth living anymore.
- D. The client needs the flu and pneumonia vaccines.
Correct Answer: C
Rationale: Suicidal ideation indicates a mental health crisis, requiring immediate intervention. Gastrostomy refusal, disclosure to fiancé, and vaccines are less urgent.
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The client diagnosed with an acute exacerbation of SLE is being discharged with a prescription for an oral steroid which will be discontinued gradually. Which statement is the scientific rationale for this type of medication dosing?
- A. Tapering the medication prevents the client from having withdrawal symptoms.
- B. So the thyroid gland starts working, because this medication stops it from working.
- C. Tapering the dose allows the adrenal glands to begin to produce cortisol again.
- D. This is the health-care provider's personal choice in prescribing the medication.
Correct Answer: C
Rationale: Tapering steroids allows adrenal glands to resume cortisol production, preventing adrenal insufficiency. Withdrawal symptoms are secondary, thyroid is unaffected, and it’s not provider preference.
The 30-year-old female client is admitted with complaints of numbness, tingling, a crawling sensation affecting the extremities, and double vision which has occurred two (2) times in the month. Which question is most important for the nurse to ask the client?
- A. Have you experienced any difficulty with your menstrual cycle?
- B. Have you noticed a rash across the bridge of your nose?
- C. Do you get tired easily and sometimes have problems swallowing?
- D. Are you taking birth control pills to prevent conception?
Correct Answer: C
Rationale: Fatigue and dysphagia are MS symptoms, and their presence supports the diagnosis. Menstrual issues, rashes (SLE-related), and birth control are less relevant to MS.
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.
The nurse is assessing a client diagnosed with RA. Which assessment findings warrant immediate intervention?
- A. The client complains of joint stiffness and the knees feel warm to the touch.
- B. The client has experienced one (1)-kg weight loss and is very tired.
- C. The client requires a heating pad applied to the hips and back to sleep.
- D. The client is crying, has a flat facial affect, and refuses to speak to the nurse.
Correct Answer: D
Rationale: Crying, flat affect, and refusal to speak suggest depression or suicidal ideation, requiring immediate intervention. Stiffness, weight loss, and heating pad use are expected in RA.
The nurse is developing a care plan for a client diagnosed with SLE. Which goal is priority for this client?
- A. The client will maintain reproductive ability.
- B. The client will verbalize feelings of body-image changes.
- C. The client will have no deterioration of organ function.
- D. The client’s skin will remain intact and have no irritation.
Correct Answer: C
Rationale: Preventing organ deterioration is critical in SLE to avoid life-threatening complications. Reproduction, body image, and skin integrity are secondary.