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Which discharge instruction should the nurse implement for the client newly diagnosed with myasthenia gravis (MG)?
- A. Identify specific measures to help avoid fatigue and undue stress.
- B. Instruct the client to pad bony prominences, especially the sacral area.
- C. Discuss complementary therapies to help manage pain.
- D. Explain the possibility of having a splenectomy to help control the symptoms.
Correct Answer: A
Rationale: Avoiding fatigue and stress prevents myasthenia gravis exacerbations. Padding, pain therapies, and splenectomy are irrelevant.
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Which referral should the nurse implement for a client with severe multiple allergies?
- A. Registered dietitian.
- B. Occupational therapist.
- C. Recreational therapist.
- D. Social worker.
Correct Answer: A
Rationale: A dietitian helps identify food allergens, critical for severe allergies. Other therapists are less relevant.
The client diagnosed with an acute exacerbation of SLE is prescribed high-dose steroids. Which statement best explains the scientific rationale for using high-dose steroids in treating SLE?
- A. The steroids will increase the body's ability to fight the infection.
- B. The steroids will decrease the chance of the SLE spreading to other organs.
- C. The steroids will suppress tissue inflammation, which reduces damage to organs.
- D. The steroids will prevent scarring of skin tissues associated with SLE.
Correct Answer: C
Rationale: Steroids suppress inflammation in SLE, reducing organ damage. They do not fight infection, prevent disease spread, or address skin scarring primarily.
The client diagnosed with myasthenia gravis is admitted with an acute exacerbation. Which interventions should the nurse implement? Select all that apply.
- A. Assist the client to turn and cough every two (2) hours.
- B. Place the client in a high or semi-Fowler's position.
- C. Assess the client's pulse oximeter reading every shift.
- D. Plan meals to promote medication effectiveness.
- E. Monitor the client's serum anticholinesterase levels.
Correct Answer: A,B,C,D
Rationale: Turning/coughing, Fowler’s position, pulse oximetry, and meal timing address respiratory risk and medication efficacy in myasthenia gravis. Serum anticholinesterase levels are not routinely monitored.
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 is caring for a client who has Systemic Inflammatory Response Syndrome (SIRS) following a major abdominal surgery. Which signs and symptoms would the nurse observe that indicate SIRS? Select all that apply.
- A. Bleeding times are increased and platelet counts decreased.
- B. Increased urine osmolality and decreased urine output.
- C. Four plus pitting edema of the lower extremities.
- D. Confusion, disorientation, delirium.
- E. Heart rate 78, blood pressure 124/84, and RR of 20.
Correct Answer: A,B,D
Rationale: SIRS presents with coagulopathy (bleeding/platelet issues), renal dysfunction (oliguria, high osmolality), and altered mental status. Pitting edema and normal vital signs are not diagnostic.