Nokea
The nurse is performing an assessment on a client with a diagnosis of systemic lupus erythematosus (SLE). Which finding should the nurse expect to note? Select all that apply.
- A. Fever
- B. Bradycardia
- C. Lymphadenopathy
- D. Butterfly rash on the face
- E. Muscular aches and pains
Correct Answer: A,C,D,E
Rationale: Manifestations of SLE may include fever, musculoskeletal aches and pains, butterfly rash on the face, pleural effusion, basilar pneumonia, generalized lymphadenopathy, pericarditis, tachycardia, hepatosplenomegaly, nephritis, delirium, seizures, psychosis, and coma.
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A client diagnosed with multiple sclerosis is prescribed baclofen. Which assessment finding would indicate to the nurse that the client is experiencing a therapeutic response from the medication?
- A. Decreased nausea
- B. Decreased muscle spasms
- C. Increased muscle tone and strength
- D. Increased range of motion of all extremities
Correct Answer: B
Rationale: Baclofen is a skeletal muscle relaxant and acts at the spinal cord level to decrease the frequency and amplitude of muscle spasms in clients with spinal cord injuries or diseases, or multiple sclerosis. None of the other options are related to the effects of this medication.
The nurse is caring for a client with a tracheostomy. Which of the following actions is the highest priority to maintain airway patency?
- A. Suctioning the tracheostomy as needed.
- B. Cleaning the tracheostomy site daily.
- C. Humidifying the inspired air.
- D. Securing the tracheostomy tube.
Correct Answer: A
Rationale: Suctioning as needed is the highest priority to maintain airway patency by removing mucus or obstructions from the tracheostomy.
The nurse is caring for a client with a new colostomy. Which statement by the client indicates a need for further teaching?
- A. I should change the pouch every 5 to 7 days.'
- B. I can eat high-fiber foods to promote regular bowel movements.'
- C. I should avoid gas-forming foods like beans.'
- D. I need to drink 2 to 3 liters of fluid daily.'
Correct Answer: B
Rationale: High-fiber foods may cause blockages in a new colostomy. The client should start with a low-residue diet and gradually introduce fiber, indicating a need for further teaching.
Select the opioid classification that is accurately coupled with an example of it AND a side effect or adverse reaction to it.
- A. Opioid Agonist: Dilaudid: Constipation
- B. Opioid Agonist: Naloxone: Constipation
- C. Opioid Antagonist: Dilaudid: Anaphylaxis
- D. Opioid Antagonist: OxyContin: Anaphylaxis
Correct Answer: A
Rationale: Dilaudid (hydromorphone) is an opioid agonist, and constipation is a common side effect due to opioid effects on the gastrointestinal tract.
The nurse is caring for a client with a history of atrial fibrillation who is prescribed dronedarone (Multaq). The nurse should monitor the client for which of the following side effects?
- A. Hypertension.
- B. Bradycardia.
- C. Liver toxicity.
- D. Weight gain.
Correct Answer: C
Rationale: Dronedarone can cause liver toxicity, requiring regular monitoring of liver function tests.