Nokea
The nurse is assessing a client diagnosed with RA. Which assessment findings warrant immediate intervention?
- A. The client complains of joint stiffness and the knees feel warm to the touch.
- B. The client has experienced one (1)-kg weight loss and is very tired.
- C. The client requires a heating pad applied to the hips and back to sleep.
- D. The client is crying, has a flat facial affect, and refuses to speak to the nurse.
Correct Answer: D
Rationale: Crying, flat affect, and refusal to speak suggest depression or suicidal ideation, requiring immediate intervention. Stiffness, weight loss, and heating pad use are expected in RA.
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The client diagnosed with a bee sting allergy is being discharged from the emergency department. Which priority discharge instruction should be taught to the client?
- A. Demonstrate how to use an EpiPen, an adrenergic agonist.
- B. Teach the client to never go outdoors in the spring and summer.
- C. Have the client buy diphenhydramine over the counter to use when stung.
- D. Discuss wearing a Medic Alert bracelet when going outside.
Correct Answer: A
Rationale: EpiPen use is critical for managing anaphylaxis in bee sting allergies. Avoiding outdoors is impractical, diphenhydramine is secondary, and bracelets are supportive.
The nurse on a medical floor is caring for clients diagnosed with AIDS. Which client should be seen first?
- A. The client who has flushed, warm skin with tented turgor.
- B. The client who states the staff ignores the call light.
- C. The client whose vital signs are T 99.9°F, P 101, R 26, and BP 110/68.
- D. The client who is unable to provide a sputum specimen.
Correct Answer: C
Rationale: Fever, tachycardia, and tachypnea suggest infection or sepsis, requiring immediate assessment. Dehydration, call light complaints, and sputum issues are less acute.
The 30-year-old female client is admitted with complaints of numbness, tingling, a crawling sensation affecting the extremities, and double vision which has occurred two (2) times in the month. Which question is most important for the nurse to ask the client?
- A. Have you experienced any difficulty with your menstrual cycle?
- B. Have you noticed a rash across the bridge of your nose?
- C. Do you get tired easily and sometimes have problems swallowing?
- D. Are you taking birth control pills to prevent conception?
Correct Answer: C
Rationale: Fatigue and dysphagia are MS symptoms, and their presence supports the diagnosis. Menstrual issues, rashes (SLE-related), and birth control are less relevant to MS.
The client diagnosed with Guillain-Barré syndrome is on a ventilator. When the wife comes to visit, she starts crying uncontrollably, and the client starts fighting the ventilator because his wife is upset. Which action should the nurse implement?
- A. Tell the wife she must stop crying.
- B. Escort the wife out of the room.
- C. Medicate the client immediately.
- D. Acknowledge the wife's fears.
Correct Answer: D
Rationale: Acknowledging the wife’s fears provides emotional support, potentially calming both her and the client. Ordering her to stop, escorting her out, or medicating the client are less therapeutic.
The client diagnosed with Guillain-Barré syndrome is on a ventilator. Which intervention will assist the client to communicate with the nursing staff?
- A. Provide an erase slate board for the client to write on.
- B. Instruct the client to blink once for 'no' and twice for 'yes.'
- C. Refer to a speech therapist to help with communication.
- D. Leave the call light within easy reach of the client.
Correct Answer: B
Rationale: Blinking (once for no, twice for yes) is a simple communication method for a ventilated client with paralysis. Writing, speech therapy, and call light access are less feasible.