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The nurse is explaining Systemic Inflammatory Response Syndrome (SIRS) to the client's significant other. Which statement best describes SIRS?
- A. SIRS is a response of the body when it has sustained a major burn or crushing injury in a motor-vehicle accident.
- B. SIRS is a response by the body to some type of injury or insult; the insult can be infectious or noninfectious in nature.
- C. SIRS only occurs when the body is overwhelmed with an infectious organism such as streptococcus bacteria.
- D. SIRS occurs when the body is allergic to the prescribed antibiotic and the body tries to recover from the allergic response.
Correct Answer: B
Rationale: SIRS is a systemic response to various insults (e.g., infection, trauma, surgery), not limited to specific causes. Burns, infections, and allergies are subsets.
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The nurse is admitting a client diagnosed with multiple sclerosis. Which clinical manifestation should the nurse assess? Select all that apply.
- A. Muscle flaccidity.
- B. Lethargy.
- C. Dysmetria.
- D. Fatigue.
- E. Dysphagia.
Correct Answer: C,D,E
Rationale: MS causes dysmetria (impaired coordination), fatigue, and dysphagia due to neurological damage. Muscle flaccidity is atypical (spasticity is common), and lethargy is non-specific.
The client on a medical floor is diagnosed with HIV encephalopathy. Which client problem is priority?
- A. Altered nutrition, less than body requirements.
- B. Anticipatory grieving.
- C. Knowledge deficit, procedures and prognosis.
- D. Risk for injury.
Correct Answer: D
Rationale: HIV encephalopathy increases confusion and motor deficits, making risk for injury the priority. Nutrition, grieving, and knowledge are secondary.
Which type of isolation technique is designed to decrease the risk of transmission of recognized and unrecognized sources of infections?
- A. Contact Precautions.
- B. Airborne Precautions.
- C. Droplet Precautions.
- D. Standard Precautions.
Correct Answer: D
Rationale: Standard Precautions reduce transmission of all infections by assuming all patients are infectious. Contact, airborne, and droplet precautions are for specific transmission modes.
The client in the HCP's office has a red, raised rash covering the forearms, neck, and face and is experiencing extreme itching which is diagnosed as an allergic reaction to poison ivy. Which discharge instructions should the nurse teach?
- A. Tell the client never to scratch the rash.
- B. Instruct the client in administering IM Benadryl.
- C. Explain how to take a steroid dose pack.
- D. Have the client wear shirts with long sleeves and high necks.
Correct Answer: C
Rationale: A steroid dose pack reduces inflammation and itching in poison ivy reactions. Never scratching is unrealistic, IM Benadryl is HCP-administered, and clothing is preventive.
The client diagnosed with myasthenia gravis is being discharged home. Which intervention has priority when teaching the client's significant others?
- A. Discuss ways to help prevent choking episodes.
- B. Explain how to care for a client on a ventilator.
- C. Teach how to perform passive range-of-motion exercises.
- D. Demonstrate how to care for the client's feeding tube.
Correct Answer: A
Rationale: Preventing choking is critical due to dysphagia in myasthenia gravis. Ventilator care, ROM, and feeding tubes are less common or secondary.