Nokea
The nurse is preparing to administer morning medications. Which medication should the nurse administer first?
- A. The pain medication to a client diagnosed with RA.
- B. The diuretic medication to a client diagnosed with SLE.
- C. The steroid to a client diagnosed with polymyositis.
- D. The appetite stimulant to a client diagnosed with OA.
Correct Answer: C
Rationale: Steroids for polymyositis address inflammation and muscle weakness, a priority in autoimmune disease. Pain, diuresis, and appetite are less urgent.
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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 Guillain-Barré syndrome asks the nurse, 'Will I ever get back to normal? I am so tired of being sick.' Which statement is the best response by the nurse?
- A. You should make a full recovery within a few months to a year.
- B. Most clients with this syndrome have some type of residual disability.
- C. This is something you should discuss with the health-care team.
- D. The rehabilitation is short and you should be fully recovered within a month.
Correct Answer: A
Rationale: Most clients with Guillain-Barré syndrome recover fully within months to a year. Residual disability is less common, deferring to the team avoids education, and one-month recovery is unrealistic.
The client diagnosed with multiple sclerosis is having trouble maintaining balance. Which intervention should the nurse discuss with the client?
- A. Discuss obtaining a motorized wheelchair for the client.
- B. Teach the client to stand with the feet slightly apart.
- C. Encourage the client to narrow his or her base of support.
- D. Explain the need to balance activity with rest.
Correct Answer: B
Rationale: Standing with feet apart widens the base of support, improving balance in MS. Wheelchairs are premature, narrowing support worsens balance, and rest is secondary.
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.
Which client problem is priority for a client diagnosed with RA?
- A. Activity intolerance.
- B. Fluid and electrolyte imbalance.
- C. Alteration in comfort.
- D. Excessive nutritional intake.
Correct Answer: C
Rationale: Chronic pain (alteration in comfort) is a hallmark of RA, impacting quality of life. Activity intolerance, fluid balance, and nutrition are secondary.