Nokea
Which intervention should the nurse implement for the client diagnosed with systemic sclerosis (scleroderma)?
- A. Instill artificial tears four (4) times a day.
- B. Apply moisturizers to the skin frequently.
- C. Instruct the client on how to apply braces.
- D. Encourage the client to decrease smoking.
Correct Answer: B
Rationale: Frequent moisturizers combat skin fibrosis in scleroderma. Artificial tears are for Sjögren’s, braces are unrelated, and smoking cessation is secondary.
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The client comes to the emergency department complaining of dyspnea and wheezing after eating at a seafood restaurant. The client cannot speak and has a bluish color around the mouth. Which intervention should the nurse implement first?
- A. Initiate an IV with normal saline.
- B. Prepare to intubate the client.
- C. Administer oxygen at 100%.
- D. Ask the client about an iodine allergy.
Correct Answer: C
Rationale: Administering 100% oxygen addresses immediate hypoxia in anaphylaxis, per ABCs. IV fluids, intubation, and allergy history follow.
The client diagnosed with myasthenia gravis is being discharged home. Which intervention has priority when teaching the client's significant others?
- A. Discuss ways to help prevent choking episodes.
- B. Explain how to care for a client on a ventilator.
- C. Teach how to perform passive range-of-motion exercises.
- D. Demonstrate how to care for the client's feeding tube.
Correct Answer: A
Rationale: Preventing choking is critical due to dysphagia in myasthenia gravis. Ventilator care, ROM, and feeding tubes are less common or secondary.
The client is diagnosed with Multi Organ Dysfunction Syndrome (MODS). Which is the most appropriate goal for the nurse to write when planning the client's care?
- A. The client will maintain vital signs within normal limits during the next 24 hours.
- B. The client's urine output will be maintained to achieve output of 600 mL in the next 24 hours.
- C. The client will have elevated ALT, AST, and GGT liver enzymes within the next 24 hours.
- D. The client's blood glucose reading will be 200 to 240 mg/dL for the next 24 hours.
Correct Answer: A
Rationale: Maintaining normal vital signs is a broad, achievable goal in MODS. Urine output is specific, elevated enzymes are undesirable, and high glucose is not a goal.
The client is prescribed a prick epicutaneous test to determine the cause of hypersensitivity reactions. Which result indicates the client is hypersensitive to the allergen?
- A. The client complains of shortness of breath.
- B. The skin is dry, intact, and without redness.
- C. The pricked blood tests positive for allergens.
- D. A pruritic wheal and erythema occur.
Correct Answer: D
Rationale: A pruritic wheal and erythema at the prick site indicate a positive allergic response. Shortness of breath is systemic, dry skin is negative, and blood tests are separate.
The nurse is caring for clients on a medical floor. Which client should be assessed first?
- A. The client diagnosed with SLE who is complaining of chest pain.
- B. The client diagnosed with MS who is complaining of pain at a '10.'
- C. The client diagnosed with myasthenia gravis who has dysphagia.
- D. The client diagnosed with GB syndrome who can barely move his toes.
Correct Answer: A
Rationale: Chest pain in SLE may indicate pericarditis or pleuritis, potentially life-threatening, requiring immediate assessment. Severe pain, dysphagia, and toe weakness are less acute.