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Which signs/symptoms should the nurse expect to assess in the client diagnosed with Sjögren's syndrome?
- A. Complaints of dry mouth and eyes.
- B. Complaints of peripheral joint pain.
- C. Complaints of muscle weakness.
- D. Complaints of severe itching.
Correct Answer: A
Rationale: Dry mouth and eyes (sicca symptoms) are hallmark signs of Sjögren’s syndrome. Joint pain, weakness, and itching are less specific.
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The nurse is assessing a client diagnosed with RA. Which assessment findings warrant immediate intervention?
- A. The client complains of joint stiffness and the knees feel warm to the touch.
- B. The client has experienced one (1)-kg weight loss and is very tired.
- C. The client requires a heating pad applied to the hips and back to sleep.
- D. The client is crying, has a flat facial affect, and refuses to speak to the nurse.
Correct Answer: D
Rationale: Crying, flat affect, and refusal to speak suggest depression or suicidal ideation, requiring immediate intervention. Stiffness, weight loss, and heating pad use are expected in RA.
The nurse writes the client problem of 'altered sexual functioning' for a male client diagnosed with multiple sclerosis (MS). Which intervention should be implemented?
- A. Encourage the couple to explore alternative ways of maintaining intimacy.
- B. Make an appointment with a psychotherapist to counsel the couple.
- C. Explain daily exercise will help increase libido and sexual arousal.
- D. Discuss the importance of keeping physically calm during sexual intercourse.
Correct Answer: A
Rationale: Exploring alternative intimacy methods addresses MS-related sexual dysfunction holistically. Psychotherapy is secondary, exercise may not improve libido, and physical calm is vague.
Which sign/symptom makes the nurse suspect the client has ankylosing spondylitis?
- A. Low back pain at night relieved by activity in the morning.
- B. Ascending paralysis of the lower extremities up to the spinal cord.
- C. A deep ache and stiffness in the hip joints radiating down the legs.
- D. Difficulty changing from lying to sitting position, especially at night.
Correct Answer: A
Rationale: Nighttime low back pain relieved by morning activity is classic for ankylosing spondylitis. Paralysis, hip pain, and positional difficulty suggest other conditions.
The client is highly allergic to insect venom and is prescribed venom immunotherapy. Which statement is the scientific rationale for this treatment?
- A. Immunotherapy is effective in preventing anaphylaxis following a future sting.
- B. Immunotherapy will prevent all future insect stings from harming the client.
- C. This therapy will cure the client from having any allergic reactions in the future.
- D. This therapy is experimental and should not be undertaken by the client.
Correct Answer: A
Rationale: Venom immunotherapy desensitizes the immune system, reducing anaphylaxis risk. It does not prevent stings, cure all allergies, or remain experimental.
The nurse caring for a client diagnosed with Multi Organ Dysfunction Syndrome (MODS) is preparing to administer morning medications. Which medication would the nurse question?
- A. Cefazolin sodium IVPB every six (6) hours.
- B. Furosemide by mouth twice daily.
- C. Metoprolol IVP every four (4) hours and prn.
- D. Acetaminophen by mouth every four (4) hours prn.
Correct Answer: C
Rationale: Metoprolol IVP every 4 hours in MODS risks hypotension in cardiovascular dysfunction. Cefazolin, furosemide, and acetaminophen are appropriate.