Nokea
The primary nurse is administering medications to the assigned clients. Which client situation requires immediate intervention by the charge nurse?
- A. The client with congestive heart failure with an apical pulse of 64 who received 0.125 mg digoxin, a cardiac glycoside.
- B. The client with essential hypertension who received a beta blocker and has a blood pressure of 114/80.
- C. The client with myasthenia gravis who received the anticholinesterase medication 30 minutes late.
- D. The client with AIDS who received trimethoprim-sulfamethoxazole, an antibiotic, and has a CD4 cell count of less than 200.
Correct Answer: C
Rationale: A 30-minute delay in anticholinesterase for myasthenia gravis risks muscle weakness exacerbation, requiring intervention. Digoxin, beta blocker, and antibiotic administration are appropriate.
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The client who has engaged in needle-sharing activities has developed a flu-like illness. An HIV antibody test is negative. Which statement best describes the scientific rationale for this finding?
- A. The client is fortunate not to have contracted HIV from an infected needle.
- B. The client must be repeatedly exposed to HIV before becoming infected.
- C. The client may be in the primary infection phase of an HIV infection.
- D. The antibody test is negative because the client has a different flu virus.
Correct Answer: C
Rationale: A negative antibody test during flu-like symptoms may indicate the primary HIV infection phase, before seroconversion. Single exposure can infect, and flu viruses are unrelated.
The nurse enters the room of a female client diagnosed with SLE and finds the client crying. Which statement is the most therapeutic response?
- A. I know you are upset, but stress makes the SLE worse.
- B. Please explain to me why you are crying.
- C. I recommend going to an SLE support group.
- D. I see you are crying. We can talk if you would like.
Correct Answer: D
Rationale: Acknowledging crying and offering to talk is therapeutic, encouraging emotional expression. Linking stress to SLE, demanding explanations, or suggesting groups are less supportive.
The 45-year-old client is diagnosed with primary progressive multiple sclerosis and the nurse writes the nursing diagnosis 'anticipatory grieving related to progressive loss.' Which intervention should be implemented first?
- A. Consult the physical therapist for assistive devices for mobility.
- B. Determine if the client has a legal power of attorney.
- C. Ask if the client would like to talk to the hospital chaplain.
- D. Discuss the client's wishes regarding end-of-life care.
Correct Answer: C
Rationale: Addressing anticipatory grieving involves exploring spiritual or emotional support, like a chaplain visit. Mobility devices, legal documents, and end-of-life discussions are secondary.
The nurse caring for the client diagnosed with Guillain-Barré syndrome writes the client problem 'impaired physical mobility.' Which long-term goal should be written for this problem?
- A. The client will have no skin irritation.
- B. The client will have no muscle atrophy.
- C. The client will perform range-of-motion exercises.
- D. The client will turn every two (2) hours while awake.
Correct Answer: C
Rationale: Performing range-of-motion exercises is a measurable long-term goal to improve mobility. Skin irritation, atrophy prevention, and turning are interventions, not goals.
Which assessment data should make the nurse suspect the client has chronic allergies?
- A. Jaundiced sclera and jaundiced palms of hands.
- B. Pale, boggy, edematous nasal mucosa.
- C. Lacy white plaques on the oral mucosa.
- D. Purple or blue patches on the face.
Correct Answer: B
Rationale: Pale, boggy, edematous nasal mucosa indicates chronic allergic rhinitis. Jaundice, oral plaques, and facial patches suggest other conditions.