Nokea
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.
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The nurse is assessing a client with cutaneous lupus erythematosus. Which intervention should be implemented?
- A. Use astringent lotion on the face and skin.
- B. Inspect the skin weekly for open areas or rashes.
- C. Dry the skin thoroughly by patting.
- D. Apply anti-itch medication between the toes.
Correct Answer: C
Rationale: Patting the skin dry prevents irritation in cutaneous lupus. Astringents worsen dryness, weekly inspections are too infrequent, and toe medication is irrelevant.
The client is highly allergic to insect venom and is prescribed venom immunotherapy. Which statement is the scientific rationale for this treatment?
- A. Immunotherapy is effective in preventing anaphylaxis following a future sting.
- B. Immunotherapy will prevent all future insect stings from harming the client.
- C. This therapy will cure the client from having any allergic reactions in the future.
- D. This therapy is experimental and should not be undertaken by the client.
Correct Answer: A
Rationale: Venom immunotherapy desensitizes the immune system, reducing anaphylaxis risk. It does not prevent stings, cure all allergies, or remain experimental.
The nurse is caring for a client diagnosed with Systemic Inflammatory Response syndrome after an extensive abdominal surgery. Which nursing interventions could prevent the development of Multi Organ Dysfunction Syndrome (MODS)?
- A. Place the client on strict intake and output.
- B. Administer pain medication via patient-controlled analgesia.
- C. Keep the head of the bed elevated at all times.
- D. Practice therapeutic communication.
Correct Answer: A
Rationale: Strict intake and output monitoring detects early renal dysfunction, preventing MODS progression. Pain control, head elevation, and communication are less specific.
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.
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.