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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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Which statement indicates the female client with systemic lupus erythematosus (SLE) understands the discharge instructions?
- A. I should wear sunscreen with at least a 5 SPF.
- B. I am not going to any activities with large crowds.
- C. I should not get pregnant because I have SLE.
- D. I must avoid using hypoallergenic products.
Correct Answer: C
Rationale: Avoiding pregnancy prevents SLE complications, indicating understanding. SPF 5 is inadequate, crowd avoidance is not standard, and hypoallergenic products are safe.
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 caring for a client who is HIV positive is stuck with the stylet used to start an IV. Which intervention should the nurse implement first?
- A. Flush the skin with water and try to get the area to bleed.
- B. Notify the charge nurse and complete an incident report.
- C. Report to the employee health nurse for prophylactic medication.
- D. Follow up with the infection control nurse to have laboratory work done.
Correct Answer: A
Rationale: Flushing and inducing bleeding at the site immediately reduces viral load. Notification, prophylaxis, and lab work follow.
The client is experiencing an anaphylactic reaction to bee venom. Which interventions should the nurse implement? List in order of priority.
- A. Establish a patent airway.
- B. Administer epinephrine, an adrenergic agonist, IVP.
- C. Start an IV with 0.9% saline.
- D. Teach the client to carry an EpiPen when outside.
- E. Administer diphenhydramine (Benadryl), an antihistamine, IVP.
Correct Answer: A,B,C,E,D
Rationale: Priority: 1) Airway (ABCs); 2) Epinephrine (reverse anaphylaxis); 3) IV fluids (support hemodynamics); 4) Diphenhydramine (reduce histamine effects); 5) EpiPen teaching (prevention).
The client diagnosed with AIDS is complaining of a sore mouth and tongue. When the nurse assesses the buccal mucosa, the nurse notes white, patchy lesions covering the hard and soft palates and the right inner cheek. Which interventions should the nurse implement?
- A. Teach the client to brush the teeth and patchy area with a soft-bristle toothbrush.
- B. Notify the HCP for an order for an antifungal swish-and-swallow medication.
- C. Have the client gargle with an antiseptic-based mouthwash several times a day.
- D. Determine what types of food the client has been eating for the last 24 hours.
Correct Answer: B
Rationale: White, patchy lesions suggest oral candidiasis, common in AIDS, requiring antifungal medication. Brushing may worsen lesions, antiseptic mouthwash is insufficient, and diet history is secondary.