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Which intervention has the highest priority when caring for a client diagnosed with rheumatoid arthritis?
- A. Encourage the client to ventilate feelings about the disease process.
- B. Discuss the effects of disease on the client's career and other life roles.
- C. Instruct the client to perform most important activities in the morning.
- D. Teach the client the proper use of hot and cold therapy to provide pain relief.
Correct Answer: D
Rationale: Hot and cold therapy directly relieves RA pain, a priority. Emotional ventilation, career impact, and morning activity are secondary.
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The client is being evaluated to rule out myasthenia gravis and being administered the Tensilon (edrophonium chloride) test. Which response to the test indicates the client has myasthenia gravis?
- A. The client has no apparent change in the assessment data.
- B. There is increased amplitude of electrical stimulation in the muscle.
- C. The circulating acetylcholine receptor antibodies are decreased.
- D. The client shows a marked improvement of muscle strength.
Correct Answer: D
Rationale: The Tensilon test improves muscle strength in myasthenia gravis by inhibiting acetylcholinesterase. No change, electrical stimulation, or antibody levels are not diagnostic.
The nurse on a medical unit has received the morning shift report. Which client should the nurse assess first?
- A. The client who has a 0730 sliding-scale insulin order.
- B. The client who received an initial dose of IV antibiotic at 0645.
- C. The client who is having back pain at a '4' on a 1-to-10 scale.
- D. The client who has dysphagia and needs to be fed.
Correct Answer: A
Rationale: The 0730 insulin order is time-sensitive to prevent hyperglycemia or hypoglycemia. Antibiotic monitoring, mild pain, and dysphagia are less urgent.
The client newly diagnosed with multiple sclerosis (MS) states, 'I don't understand how I got multiple sclerosis. Is it genetic?' On which statement should the nurse base the response?
- A. Genetics may play a role in susceptibility to MS, but the disease may be caused by a virus.
- B. There is no evidence suggesting there is any chromosomal involvement in developing MS.
- C. Multiple sclerosis is caused by a recessive gene, so both parents had to have the gene for the client to get MS.
- D. Multiple sclerosis is caused by an autosomal dominant gene on the Y chromosome, so only fathers can pass it on.
Correct Answer: A
Rationale: MS has a genetic susceptibility component (e.g., HLA genes), but environmental factors like viral infections may trigger it. There is chromosomal involvement, MS is not purely recessive or dominant, and it is not Y-linked.
The nurse is planning the care for a client diagnosed with RA. Which intervention should be implemented?
- A. Plan a strenuous exercise program.
- B. Order a mechanical soft diet.
- C. Maintain a keep-open IV.
- D. Obtain an order for a sedative.
Correct Answer: C
Rationale: A keep-open IV ensures access for RA medications (e.g., biologics). Strenuous exercise worsens joints, soft diets are unrelated, and sedatives are not routine.
The client with myasthenia gravis is undergoing plasmapheresis at the bedside. Which assessment data warrant immediate intervention?
- A. The client's BP is 94/60 and AP is 112.
- B. Negative Chvostek's and Trousseau's signs.
- C. The serum potassium level is 3.5 mEq/L.
- D. Ecchymosis at the vascular site access.
Correct Answer: A
Rationale: Hypotension (BP 94/60) and tachycardia (AP 112) during plasmapheresis suggest hypovolemia or reaction, requiring immediate intervention. Negative signs, normal potassium, and ecchymosis are less urgent.