Nokea
The nurse is admitting a client diagnosed with R/O SLE. Which assessment data observed by the nurse support the diagnosis of SLE?
- A. Pericardial friction rub and crackles in the lungs.
- B. Muscle spasticity and bradykinesia.
- C. Hirsutism and clubbing of the fingers.
- D. Somnolence and weight gain.
Correct Answer: A
Rationale: Pericardial friction rub and lung crackles indicate serositis, common in SLE. Spasticity, hirsutism, and somnolence suggest other conditions.
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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.
Which is the highest priority nursing intervention for the client who is having an anaphylactic reaction?
- A. Administer parenteral epinephrine, an adrenergic agonist.
- B. Prepare for immediate endotracheal intubation.
- C. Provide a calm assurance when caring for the client.
- D. Establish and maintain a patent airway.
Correct Answer: D
Rationale: Establishing a patent airway is the highest priority in anaphylaxis, per ABCs. Epinephrine, intubation, and reassurance follow.
The client diagnosed with RA who has been prescribed etanercept, a tumor necrosis factor alpha inhibitor, shows marked improvement. Which instruction regarding the use of this medication should the nurse teach?
- A. Explain the medication loses its efficacy after a few months.
- B. Continue to have checkups and laboratory work while taking the medication.
- C. Have yearly magnetic resonance imaging to follow the progress.
- D. Discuss the drug is taken for three (3) weeks and then stopped for a week.
Correct Answer: B
Rationale: Regular checkups and lab work monitor for etanercept side effects (e.g., infection). Efficacy persists, MRI is not routine, and cycling is incorrect.
Which client problem is priority for a client diagnosed with RA?
- A. Activity intolerance.
- B. Fluid and electrolyte imbalance.
- C. Alteration in comfort.
- D. Excessive nutritional intake.
Correct Answer: C
Rationale: Chronic pain (alteration in comfort) is a hallmark of RA, impacting quality of life. Activity intolerance, fluid balance, and nutrition are secondary.
Which sign/symptom should the nurse expect to assess in the client who is in the recovery stage of Guillain-Barré syndrome?
- A. Decreasing deep tendon reflexes.
- B. Drooping of the eyelids has resolved.
- C. A positive Babinski's reflex.
- D. Descending increase in muscle strength.
Correct Answer: D
Rationale: Recovery in Guillain-Barré syndrome shows descending muscle strength improvement. Reflexes improve, ptosis is unrelated, and Babinski’s is not typical.