Nokea
Which collaborative health-care team member should the nurse refer the client to in the late stages of myasthenia gravis?
- A. Occupational therapist.
- B. Recreational therapist.
- C. Vocational therapist.
- D. Speech therapist.
Correct Answer: D
Rationale: Speech therapists address dysphagia and communication issues in late-stage myasthenia gravis. Other therapists are less relevant.
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The client diagnosed with Multi Organ Dysfunction Syndrome (MODS) has renal, cardiovascular, and pulmonary dysfunction issues. Which statement by the nurse indicates an understanding of the client's prognosis?
- A. As long as the client is maintained on a ventilator, then the prognosis can be up to 60% recovery.
- B. The client will have less than a 2% potential for recovery from the MODS.
- C. When three or more body systems fail, the mortality rate can be 70% to 80%.
- D. More than one body system in failure reduces the recovery rate to 80% to 90%.
Correct Answer: C
Rationale: MODS with three or more organ failures has a 70–80% mortality rate. Ventilator use, 2% recovery, and 80–90% recovery are inaccurate.
Which nursing intervention should the nurse include when teaching the client diagnosed with polymyositis?
- A. Explain the care of a percutaneous endoscopic gastrostomy tube.
- B. Discuss the need to take corticosteroids every day.
- C. Instruct to wear long-sleeved shirts when exposed to sunlight.
- D. Teach the importance of strict hand washing.
Correct Answer: B
Rationale: Corticosteroids are mainstay treatment for polymyositis, reducing muscle inflammation. PEG tubes, sun protection, and handwashing are less relevant.
The nurse and a female unlicensed assistive personnel (UAP) are caring for a group of clients on a medical floor. Which action by the UAP warrants immediate intervention by the nurse?
- A. The UAP washes her hands before and after performing vital signs on a client.
- B. The UAP dons sterile gloves prior to removing an indwelling catheter from a client.
- C. The UAP raises the head of the bed to a high Fowler's position for a client about to eat.
- D. The UAP uses a fresh plastic bag to get ice for a client's water pitcher.
Correct Answer: B
Rationale: Sterile gloves are unnecessary for catheter removal, risking improper technique and infection. Handwashing, Fowler’s position, and ice bag use are appropriate.
The client diagnosed with RA has developed swan-neck fingers. Which referral is most appropriate for the client?
- A. Physical therapy.
- B. Occupational therapy.
- C. Psychiatric counselor.
- D. Home health nurse.
Correct Answer: B
Rationale: Occupational therapy addresses hand function and adaptive devices for swan-neck deformities. Physical therapy, counseling, and home health are less specific.
The nurse is describing the HIV virus infection to a client who has been told he is HIV positive. Which information regarding the virus is important to teach?
- A. The HIV virus is a retrovirus, which means it never dies as long as it has a host to live in.
- B. The HIV virus can be eradicated from the host body with the correct medical regimen.
- C. It is difficult for the HIV virus to replicate in humans because it is a monkey virus.
- D. The HIV virus uses the client's own red blood cells to reproduce the virus in the body.
Correct Answer: A
Rationale: HIV is a retrovirus that persists in the host, integrating into DNA. It cannot be eradicated, is not a monkey virus, and infects CD4 cells, not red blood cells.