Nokea
What is the nurse's best response to a client with MS experiencing fatigue?
- A. Limit all activities.
- B. Schedule rest periods.
- C. Increase fluid intake.
- D. Avoid all exercise.
Correct Answer: B
Rationale: Scheduling rest periods helps manage fatigue while supporting activity in multiple sclerosis.
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A client who has been diagnosed with bladder cancer is scheduled for an ileal conduit. Preoperatively, the nurse reinforces the client's understanding of the surgical procedure by explaining that an ileal conduit:
- A. Is a temporary procedure that can be reversed later.
- B. Diverts urine into the sigmoid colon, where it is expelled through the rectum.
- C. Conveys urine from the ureters to a stoma opening on the abdomen.
- D. Creates an opening in the bladder that allows urine to drain into an external pouch.
Correct Answer: C
Rationale: An ileal conduit diverts urine from the ureters to an abdominal stoma, where it is collected in an external pouch, a permanent procedure for bladder cancer management.
Which finding indicates a properly functioning ileal conduit?
- A. Clear urine output.
- B. Mucus in the urine.
- C. Dry stoma site.
- D. No urine output.
Correct Answer: B
Rationale: Mucus in the urine is normal due to the intestinal segment used in the conduit.
A 25-year-old client taking hydroxychloroquine (Plaquenil) for rheumatoid arthritis reports difficulty seeing out of her left eye. Correct interpretation of this assessment finding indicates which of the following?
- A. Development of a cataract.
- B. Possible retinal degeneration.
- C. Part of the disease process.
- D. A coincidental occurrence.
Correct Answer: B
Rationale: Hydroxychloroquine can cause retinal toxicity, leading to vision changes. This is a known side effect requiring immediate medical evaluation.
The nurse assesses that the client with hepatitis is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. Based on this information, which of the following would be an appropriate nursing diagnosis?
- A. Impaired physical mobility related to malaise.
- B. Self-care deficit related to fatigue.
- C. Ineffective coping related to long-term illness.
- D. Activity intolerance related to fatigue.
Correct Answer: D
Rationale: Activity intolerance related to fatigue (D) accurately reflects the client's rapid tiring due to hepatitis. Impaired mobility (A), self-care deficit (B), and ineffective coping (C) are less directly supported by the symptoms described.
A client has been in an automobile accident and the nurse is assessing the client for possible pneumothorax. The nurse should assess the client for:
- A. Sudden, sharp chest pain.
- B. Wheezing breath sounds over affected side.
- C. Hemoptysis.
- D. Cyanosis.
Correct Answer: A
Rationale: Sudden, sharp chest pain is a hallmark of pneumothorax due to pleural irritation. Wheezing, hemoptysis, and cyanosis are less specific or occur later.