Nokea
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.
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The client diagnosed with myasthenia gravis is admitted to the emergency department with a sudden exacerbation of motor weakness. Which assessment data indicate the client is experiencing a cholinergic crisis?
- A. The serum assay of circulating acetylcholine receptor antibodies is increased.
- B. The client's symptoms improve when administering a cholinesterase inhibitor.
- C. The client's blood pressure, pulse, and respirations improve after IV fluid.
- D. The Tensilon test does not show improvement in the client's muscle strength.
Correct Answer: D
Rationale: Cholinergic crisis (overdose of cholinesterase inhibitors) shows no improvement with Tensilon, unlike myasthenic crisis. Antibody levels, symptom improvement, and vital signs are not specific.
The client is prescribed a prick epicutaneous test to determine the cause of hypersensitivity reactions. Which result indicates the client is hypersensitive to the allergen?
- A. The client complains of shortness of breath.
- B. The skin is dry, intact, and without redness.
- C. The pricked blood tests positive for allergens.
- D. A pruritic wheal and erythema occur.
Correct Answer: D
Rationale: A pruritic wheal and erythema at the prick site indicate a positive allergic response. Shortness of breath is systemic, dry skin is negative, and blood tests are separate.
The client is diagnosed with Multi Organ Dysfunction Syndrome (MODS). Which is the most appropriate goal for the nurse to write when planning the client's care?
- A. The client will maintain vital signs within normal limits during the next 24 hours.
- B. The client's urine output will be maintained to achieve output of 600 mL in the next 24 hours.
- C. The client will have elevated ALT, AST, and GGT liver enzymes within the next 24 hours.
- D. The client's blood glucose reading will be 200 to 240 mg/dL for the next 24 hours.
Correct Answer: A
Rationale: Maintaining normal vital signs is a broad, achievable goal in MODS. Urine output is specific, elevated enzymes are undesirable, and high glucose is not a goal.
The nurse and a licensed practical nurse (LPN) are caring for a group of clients. Which nursing task should not be assigned to the LPN?
- A. Administer a skeletal muscle relaxant to a client diagnosed with low back pain.
- B. Discuss bowel regimen medications with the HCP for the client on strict bedrest.
- C. Draw morning blood work on the client diagnosed with bacterial meningitis.
- D. Teach self-catheterization to the client diagnosed with multiple sclerosis.
Correct Answer: D
Rationale: Teaching self-catheterization requires nursing judgment and patient education, outside LPN scope. Administering medications, discussing with HCP, and drawing blood are within LPN scope.
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.