Nokea
The nurse is collecting data from a client with the autoimmune disorder endocarditis. What does the nurse recognize as symptom of an acute exacerbation?
- A. Temperature of 100.9?°F
- B. Respiratory rate of 20 breaths/minute
- C. Constipation
- D. Nausea
Correct Answer: A
Rationale: Periods of acute flare-ups (known as exacerbations) are completely unpredictable. During acute exacerbations, clients often experience a low-grade fever, malaise, or fatigue. They also may lose weight. A respiratory rate of 20 breaths/minute is within normal range. Constipation and nausea are not characteristic of a flare-up of endocarditis.
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A client informs the nurse of being very allergic to poison ivy but expresses enjoying and having several camping trips planned for the summer months. What suggestions can the nurse make to protect the client against poison ivy?
- A. Calamine lotion prior to the exposure of the poison ivy and any time skin gets wet
- B. Bentoquatam 5% applied 15 minutes prior to exposure and every 4 hours
- C. Vinegar and water applied to the skin every 2 hours
- D. Diphenhydramine (Benadryl) 50 mg taken prior to the camping trip
Correct Answer: B
Rationale: To protect against poison ivy, clients can apply bentoquatam 5% to the skin 15 minutes prior to exposure and at least every 4 hours as long as risk of exposure continues. The cream forms a protective layer on top of the skin. Calamine lotion can be used for the itching related to poison ivy exposure. Vinegar and water is not an effective way to manage the prevention of poison ivy. Benadryl will not protect against poison ivy.
A client presents to the clinic with reports of itching and hives after taking an aspirin this morning. What medication does the nurse anticipate administering that blocks histamine receptors?
- A. Diphenhydramine
- B. Flunisolide
- C. Beclomethasone dipropionate
- D. Pseudoephedrine hydrochloride
Correct Answer: A
Rationale: Diphenhydramine is an antihistamine used for allergic reactions. Flunisolide is a nasal decongestant agent and is used locally to the nasal mucosa. Beclomethasone dipropionate is a nasal steroid spray and inhalant. Pseudoephedrine hydrochloride only constricts nasal membranes.
A client with early-stage rheumatoid arthritis asks the nurse what to do to help ease the symptoms of the disease. What would be the best response by the nurse?
- A. The doctor could prescribe anti-inflammatory drugs.'
- B. The doctor could prescribe antipyretic drugs.'
- C. The doctor could prescribe antineoplastic drugs.'
- D. The doctor could prescribe antihypertensive drugs.'
Correct Answer: A
Rationale: Drug therapy using anti-inflammatory and immunosuppressive agents is the mainstay for alleviating symptoms. Antipyretic and antihypertensive drugs are not prescribed for autoimmune diseases. An antineoplastic drug is not prescribed for an autoimmune disorder until it is in its late stages and uncontrolled by the first-line drugs.
A client comes to the clinic to see the physician, reporting, 'I think I ate something that I am allergic to.' What symptoms would be appropriate for the nurse to ask questions about?
- A. Nasal congestion and coughing
- B. Hives and itching
- C. Sneezing and runny nose
- D. Diarrhea and abdominal cramping
Correct Answer: D
Rationale: Clinical manifestations generally correlate with the manner in which the allergen enters the body. Inhaled allergens usually cause respiratory symptoms, including nasal congestion, runny nose, sneezing, coughing, dyspnea, and wheezing. Contactants cause skin reactions such as hives, which appear as vesicles filled with clear fluid surrounded by a margin of redness, rash, and localized itching. Cramping, vomiting, and diarrhea are associated with ingested food allergens. Allergic skin responses may also occur with allergies to foods.
The nurse is instructing a client with chronic fatigue syndrome about what type of dietary sources are the best to eat to supply eicosapentaenoic acid (EPA). What statement by the client demonstrates the instruction is understood?
- A. I will eat shrimp at least twice a week.'
- B. I love crab cakes and will be sure to make them once a week.'
- C. Fresh salmon is one of my favorites, and I will eat it twice a week.'
- D. Lobster is expensive, but I will eat it once a week.'
Correct Answer: C
Rationale: Fish oils provide the only dietary source of EPA. Fatty fish, such as mackerel, sardines, herring, salmon, and tuna, are the best sources. Shellfish, such as shrimp, crab, and lobsters do not offer the dietary source of EPA that is required.