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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.
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The 20-year-old female client diagnosed with advanced unremitting RA is being admitted to receive a regimen of immunosuppressive medications. Which question should the nurse ask during the admission process regarding the medications?
- A. Are you sexually active, and, if so, are you using birth control?
- B. Have you discussed taking these drugs with your parents?
- C. Which arm do you prefer to have an IV in for four (4) days?
- D. Have you signed an informed consent for investigational drugs?
Correct Answer: A
Rationale: Immunosuppressants are teratogenic, making contraception critical. Parental discussion, IV preference, and investigational consent are less relevant.
The client diagnosed with Guillain-Barré syndrome is on a ventilator. When the wife comes to visit, she starts crying uncontrollably, and the client starts fighting the ventilator because his wife is upset. Which action should the nurse implement?
- A. Tell the wife she must stop crying.
- B. Escort the wife out of the room.
- C. Medicate the client immediately.
- D. Acknowledge the wife's fears.
Correct Answer: D
Rationale: Acknowledging the wife’s fears provides emotional support, potentially calming both her and the client. Ordering her to stop, escorting her out, or medicating the client are less therapeutic.
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 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 assessing a client diagnosed with RA. Which assessment findings warrant immediate intervention?
- A. The client complains of joint stiffness and the knees feel warm to the touch.
- B. The client has experienced one (1)-kg weight loss and is very tired.
- C. The client requires a heating pad applied to the hips and back to sleep.
- D. The client is crying, has a flat facial affect, and refuses to speak to the nurse.
Correct Answer: D
Rationale: Crying, flat affect, and refusal to speak suggest depression or suicidal ideation, requiring immediate intervention. Stiffness, weight loss, and heating pad use are expected in RA.