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The nurse enters the room of a female client diagnosed with SLE and finds the client crying. Which statement is the most therapeutic response?
- A. I know you are upset, but stress makes the SLE worse.
- B. Please explain to me why you are crying.
- C. I recommend going to an SLE support group.
- D. I see you are crying. We can talk if you would like.
Correct Answer: D
Rationale: Acknowledging crying and offering to talk is therapeutic, encouraging emotional expression. Linking stress to SLE, demanding explanations, or suggesting groups are less supportive.
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The client diagnosed with Guillain-Barré syndrome is having difficulty breathing and is placed on a ventilator. Which situation warrants immediate intervention by the nurse?
- A. The ventilator rate is set at 14 breaths per minute.
- B. A manual resuscitation bag is at the client's bedside.
- C. The client's pulse oximeter reading is 85%.
- D. The ABG results are pH 7.4, PaO2 88, PaCO2 35, and HCO3 24.
Correct Answer: C
Rationale: A pulse oximeter reading of 85% indicates hypoxemia, requiring immediate intervention. Ventilator rate, resuscitation bag, and normal ABGs are appropriate.
The nurse caring for the client diagnosed with Guillain-Barré syndrome writes the client problem 'impaired physical mobility.' Which long-term goal should be written for this problem?
- A. The client will have no skin irritation.
- B. The client will have no muscle atrophy.
- C. The client will perform range-of-motion exercises.
- D. The client will turn every two (2) hours while awake.
Correct Answer: C
Rationale: Performing range-of-motion exercises is a measurable long-term goal to improve mobility. Skin irritation, atrophy prevention, and turning are interventions, not goals.
The nurse in the emergency department is allergic to latex. Which intervention should the nurse implement regarding the use of nonsterile gloves?
- A. Use only sterile, nonlatex gloves for any procedure requiring gloves.
- B. Do not use gloves when starting an IV or performing a procedure.
- C. Keep a pair of nonsterile, nonlatex gloves in the pocket of the uniform.
- D. Wear white cotton gloves at all times to protect the hands.
Correct Answer: C
Rationale: Carrying nonsterile, nonlatex gloves ensures safe practice for a latex-allergic nurse. Sterile gloves are unnecessary, avoiding gloves risks infection, and cotton gloves are inadequate.
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.
Which signs/symptoms make the nurse suspect the most common opportunistic infection in the female client diagnosed with acquired immunodeficiency syndrome (AIDS)?
- A. Fever, cough, and shortness of breath.
- B. Oral thrush, esophagitis, and vaginal candidiasis.
- C. Abdominal pain, diarrhea, and weight loss.
- D. Painless violet lesions on the face and tip of nose.
Correct Answer: A
Rationale: Fever, cough, and shortness of breath indicate Pneumocystis pneumonia, the most common AIDS opportunistic infection. Candidiasis, GI symptoms, and Kaposi’s sarcoma are less frequent.