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The nurse is developing a care plan for a client diagnosed with SLE. Which goal is priority for this client?
- A. The client will maintain reproductive ability.
- B. The client will verbalize feelings of body-image changes.
- C. The client will have no deterioration of organ function.
- D. The client’s skin will remain intact and have no irritation.
Correct Answer: C
Rationale: Preventing organ deterioration is critical in SLE to avoid life-threatening complications. Reproduction, body image, and skin integrity are secondary.
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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.
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 client diagnosed with an acute exacerbation of SLE is being discharged with a prescription for an oral steroid which will be discontinued gradually. Which statement is the scientific rationale for this type of medication dosing?
- A. Tapering the medication prevents the client from having withdrawal symptoms.
- B. So the thyroid gland starts working, because this medication stops it from working.
- C. Tapering the dose allows the adrenal glands to begin to produce cortisol again.
- D. This is the health-care provider's personal choice in prescribing the medication.
Correct Answer: C
Rationale: Tapering steroids allows adrenal glands to resume cortisol production, preventing adrenal insufficiency. Withdrawal symptoms are secondary, thyroid is unaffected, and it’s not provider preference.
Which statement by the female client diagnosed with myasthenia gravis indicates the client needs more discharge teaching?
- A. I will not have any menstrual cycles because of this disease.
- B. I should avoid people who have respiratory infections.
- C. I should not take a hot bath or swim in cold water.
- D. I will drink at least 2,500 mL of water a day.
Correct Answer: A
Rationale: Myasthenia gravis does not affect menstrual cycles, indicating a need for teaching. Avoiding infections, temperature extremes, and hydration are correct.
The nurse writes the client problem of 'altered sexual functioning' for a male client diagnosed with multiple sclerosis (MS). Which intervention should be implemented?
- A. Encourage the couple to explore alternative ways of maintaining intimacy.
- B. Make an appointment with a psychotherapist to counsel the couple.
- C. Explain daily exercise will help increase libido and sexual arousal.
- D. Discuss the importance of keeping physically calm during sexual intercourse.
Correct Answer: A
Rationale: Exploring alternative intimacy methods addresses MS-related sexual dysfunction holistically. Psychotherapy is secondary, exercise may not improve libido, and physical calm is vague.