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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 client diagnosed with a bee sting allergy is being discharged from the emergency department. Which priority discharge instruction should be taught to the client?
- A. Demonstrate how to use an EpiPen, an adrenergic agonist.
- B. Teach the client to never go outdoors in the spring and summer.
- C. Have the client buy diphenhydramine over the counter to use when stung.
- D. Discuss wearing a Medic Alert bracelet when going outside.
Correct Answer: A
Rationale: EpiPen use is critical for managing anaphylaxis in bee sting allergies. Avoiding outdoors is impractical, diphenhydramine is secondary, and bracelets are supportive.
The client has had an anaphylactic reaction to insect venom, a bee sting. Which discharge instruction should the nurse discuss with the client?
- A. Take a corticosteroid dose pack when stung by a bee.
- B. Take antihistamines prior to outdoor activities.
- C. Use a cromolyn sodium (Intal) inhaler prophylactically.
- D. Carry a bee sting kit, especially when going outside.
Correct Answer: D
Rationale: Carrying a bee sting kit (EpiPen) is critical for managing future anaphylaxis. Steroids, antihistamines, and cromolyn are less effective prophylactically.
Which interventions should the nurse discuss with the female client who is positive for human immunodeficiency virus (HIV)? Select all that apply.
- A. Recommend the client not to engage in unprotected sexual activity.
- B. Instruct the client not to inform past sexual partners of HIV status.
- C. Tell the client to not donate blood, organs, or tissues.
- D. Suggest the client not get pregnant.
- E. Explain the client does not have to tell health-care personnel of HIV status.
Correct Answer: A,C,D
Rationale: Unprotected sex, blood/organ donation, and pregnancy risk HIV transmission or complications. Partner notification and informing healthcare personnel are recommended.
Which assessment intervention should the nurse implement specifically for the diagnosis of Guillain-Barré syndrome?
- A. Assess deep tendon reflexes.
- B. Complete a Glasgow Coma Scale.
- C. Check for Babinski's reflex.
- D. Take the client's vital signs.
Correct Answer: A
Rationale: Decreased deep tendon reflexes are a hallmark of Guillain-Barré syndrome due to peripheral nerve involvement. Glasgow Coma Scale, Babinski’s reflex, and vital signs are less specific.
Which signs/symptoms should the nurse expect to assess in the client diagnosed with Sjögren's syndrome?
- A. Complaints of dry mouth and eyes.
- B. Complaints of peripheral joint pain.
- C. Complaints of muscle weakness.
- D. Complaints of severe itching.
Correct Answer: A
Rationale: Dry mouth and eyes (sicca symptoms) are hallmark signs of Sjögren’s syndrome. Joint pain, weakness, and itching are less specific.