Nokea
Which ocular or facial signs/symptoms should the nurse expect to assess for the client diagnosed with myasthenia gravis?
- A. Weakness and fatigue.
- B. Ptosis and diplopia.
- C. Breathlessness and dyspnea.
- D. Weight loss and dehydration.
Correct Answer: B
Rationale: Ptosis and diplopia are hallmark ocular symptoms of myasthenia gravis due to neuromuscular weakness. General weakness, respiratory issues, and weight loss are less specific.
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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.
The 26-year-old female client is complaining of a low-grade fever, arthralgias, fatigue, and a facial rash. Which laboratory tests should the nurse expect the HCP to order if SLE is suspected?
- A. Complete metabolic panel and liver function tests.
- B. Complete blood count and antinuclear antibody tests.
- C. Cholesterol and lipid profile tests.
- D. Blood urea nitrogen and glomerular filtration tests.
Correct Answer: B
Rationale: CBC and ANA tests detect anemia, leukopenia, and autoantibodies, supporting SLE diagnosis. Metabolic, lipid, and renal tests are less specific initially.
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 school nurse is preparing to teach a health class to ninth graders regarding sexually transmitted diseases. Which information regarding acquired immunodeficiency syndrome (AIDS) should be included?
- A. Females taking birth control pills are protected from becoming infected with HIV.
- B. Protected sex is no longer an issue because there is a vaccine for the HIV virus.
- C. Adolescents with a normal immune system are not at risk for developing AIDS.
- D. Abstinence is the only guarantee of not becoming infected with sexually transmitted HIV.
Correct Answer: D
Rationale: Abstinence is the only certain way to prevent sexually transmitted HIV. Birth control pills, vaccines, and immune status do not eliminate risk.
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.