Nokea
The nurse is admitting a client diagnosed with multiple sclerosis. Which clinical manifestation should the nurse assess? Select all that apply.
- A. Muscle flaccidity.
- B. Lethargy.
- C. Dysmetria.
- D. Fatigue.
- E. Dysphagia.
Correct Answer: C,D,E
Rationale: MS causes dysmetria (impaired coordination), fatigue, and dysphagia due to neurological damage. Muscle flaccidity is atypical (spasticity is common), and lethargy is non-specific.
You may also like to solve these questions
The client in the emergency department begins to experience a severe anaphylactic reaction after an initial dose of IV penicillin, an antibiotic. Which interventions should the nurse implement? Select all that apply.
- A. Prepare to administer Solu-Medrol, a glucocorticoid, IV.
- B. Request and obtain a STAT chest x-ray.
- C. Initiate the rapid response team.
- D. Administer epinephrine, an adrenergic blocker, SQ then IV continuous.
- E. Assess the client's pulse and respirations.
Correct Answer: A,C,E
Rationale: Solu-Medrol, rapid response team, and vital sign assessment address anaphylaxis. Chest x-ray is unnecessary, and epinephrine is an agonist, not a blocker.
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 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 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 explaining Systemic Inflammatory Response Syndrome (SIRS) to the client's significant other. Which statement best describes SIRS?
- A. SIRS is a response of the body when it has sustained a major burn or crushing injury in a motor-vehicle accident.
- B. SIRS is a response by the body to some type of injury or insult; the insult can be infectious or noninfectious in nature.
- C. SIRS only occurs when the body is overwhelmed with an infectious organism such as streptococcus bacteria.
- D. SIRS occurs when the body is allergic to the prescribed antibiotic and the body tries to recover from the allergic response.
Correct Answer: B
Rationale: SIRS is a systemic response to various insults (e.g., infection, trauma, surgery), not limited to specific causes. Burns, infections, and allergies are subsets.