Nokea
The nurse and a licensed practical nurse are caring for clients in a rheumatologist's office. Which task can the nurse assign to the licensed practical nurse?
- A. Administer methotrexate, an antineoplastic medication, IV.
- B. Assess the lung sounds of a client with RA who is coughing.
- C. Demonstrate how to use clothing equipped with Velcro fasteners.
- D. Discuss methods of birth control compatible with treatment medications.
Correct Answer: C
Rationale: Demonstrating Velcro clothing is within LPN scope. Methotrexate administration, lung assessment, and birth control discussion require RN judgment.
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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 client with RA has nontender, movable nodules in the subcutaneous tissue over the elbows and shoulders. Which statement is the scientific rationale for the nodules?
- A. The nodules indicate a rapidly progressive destruction of the affected tissue.
- B. The nodules are small amounts of synovial fluid that have become crystallized.
- C. The nodules are lymph nodes which have proliferated to try to fight the disease.
- D. The nodules present a favorable prognosis and mean the client is better.
Correct Answer: B
Rationale: RA nodules are granulomas, sometimes containing synovial fluid, due to chronic inflammation. They do not indicate rapid destruction, lymph node proliferation, or better prognosis.
The client diagnosed with Systemic Response Inflammatory Syndrome (SIRS) asks the nurse what the diagnosis means. Which is the nurse's best response?
- A. SIRS is a localized response to major trauma that has occurred within the last three (3) months.
- B. SIRS is a syndrome of potential responses to illness that has an optimum prognosis.
- C. SIRS is a respiratory response to the client having had a myocardial infarction or pneumonia.
- D. SIRS is a systemic response to a variety of insults, including infection, ischemia, and injury.
Correct Answer: D
Rationale: SIRS is a systemic response to insults like infection or trauma. It is not localized, has variable prognosis, and is not solely respiratory.
The wife of a client diagnosed with myasthenia gravis is crying and shares with the nurse she just doesn't know what to do. Which response is the best action by the nurse?
- A. Discuss the Myasthenia Foundation with the client's wife.
- B. Refer the client to a local myasthenia gravis support group.
- C. Ask the client's wife if she would like to talk to a counselor.
- D. Sit down and allow the wife to ventilate her feelings to the nurse.
Correct Answer: D
Rationale: Allowing the wife to ventilate feelings is therapeutic, addressing immediate emotional distress. Foundation discussion, support groups, and counseling are secondary.
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.