The nurse is admitting a client diagnosed with multiple scle...

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.

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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 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.

The client diagnosed with Guillain-Barré syndrome asks the nurse, 'Will I ever get back to normal? I am so tired of being sick.' Which statement is the best response by the nurse?

A. You should make a full recovery within a few months to a year.
B. Most clients with this syndrome have some type of residual disability.
C. This is something you should discuss with the health-care team.
D. The rehabilitation is short and you should be fully recovered within a month.

Correct Answer: A

Rationale: Most clients with Guillain-Barré syndrome recover fully within months to a year. Residual disability is less common, deferring to the team avoids education, and one-month recovery is unrealistic.

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 diagnosed with AIDS is angry and yells at everyone entering the room, and none of the staff members wants to care for the client. Which intervention is most appropriate for the nurse manager to use in resolving this situation?

A. Assign a different nurse every shift to the client.
B. Ask the HCP to tell the client not to yell at the staff.
C. Call a team meeting and discuss options with the staff.
D. Tell one (1) staff member to care for the client a week at a time.

Correct Answer: C

Rationale: A team meeting fosters collaboration to address the client’s behavior and staff concerns. Rotating nurses, HCP intervention, or single-nurse assignment are less effective.