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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 diagnosed with Multiple Organ Dysfunction Syndrome (MODS) is admitted to the intensive care department. Which assessment data are most important for the nurse to collect/monitor?
- A. Lung sounds, heart sounds, and blood pressure.
- B. The client's psychological response to the illness.
- C. The client's family's expectations of the hospitalization.
- D. Amount of emesis, bile secretions, and mouth ulcers.
Correct Answer: A
Rationale: Lung sounds, heart sounds, and BP monitor respiratory, cardiac, and hemodynamic status, critical in MODS. Psychological, family, and GI data are secondary.
The client diagnosed with Guillain-Barré syndrome is having difficulty breathing and is placed on a ventilator. Which situation warrants immediate intervention by the nurse?
- A. The ventilator rate is set at 14 breaths per minute.
- B. A manual resuscitation bag is at the client's bedside.
- C. The client's pulse oximeter reading is 85%.
- D. The ABG results are pH 7.4, PaO2 88, PaCO2 35, and HCO3 24.
Correct Answer: C
Rationale: A pulse oximeter reading of 85% indicates hypoxemia, requiring immediate intervention. Ventilator rate, resuscitation bag, and normal ABGs are appropriate.
The client diagnosed with SLE is being discharged from the medical unit. Which discharge instructions are most important for the nurse to include? Select all that apply.
- A. Use a sunscreen of SPF 30 or greater when in the sunlight.
- B. Notify the HCP immediately when developing a low-grade fever.
- C. Some dyspnea is expected and does not need immediate attention.
- D. The hands and feet may change color if exposed to cold or heat.
- E. Explain the client can be cured with continued therapy.
Correct Answer: A,B,D
Rationale: Sunscreen, fever reporting, and Raynaud’s phenomenon awareness prevent SLE flares and complications. Dyspnea requires attention, and SLE is not curable.
The nurse is admitting a client diagnosed with protein-calorie malnutrition secondary to AIDS. Which intervention should be the nurse's first intervention?
- A. Assess the client's body weight and ask what the client has been able to eat.
- B. Place in contact isolation and don a mask and gown before entering the room.
- C. Check the HCP's orders and determine what laboratory tests will be done.
- D. Teach the client about total parenteral nutrition and monitor the subclavian IV site.
Correct Answer: A
Rationale: Assessing weight and dietary intake provides baseline data for malnutrition management. Isolation is unnecessary, lab orders are secondary, and TPN teaching is premature.
The client recently diagnosed with rheumatoid arthritis is prescribed aspirin, a nonsteroidal anti-inflammatory medication. Which comment by the client warrants immediate intervention by the nurse?
- A. I always take the aspirin with food.
- B. If I have dark stools, I will call my HCP.
- C. Aspirin will not cure my arthritis.
- D. I am having some ringing in my ears.
Correct Answer: D
Rationale: Ringing in the ears (tinnitus) indicates aspirin toxicity, requiring immediate intervention. Taking with food, reporting dark stools, and understanding no cure are correct.