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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.
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The nurse is caring for a client diagnosed with Systemic Inflammatory Response syndrome after an extensive abdominal surgery. Which nursing interventions could prevent the development of Multi Organ Dysfunction Syndrome (MODS)?
- A. Place the client on strict intake and output.
- B. Administer pain medication via patient-controlled analgesia.
- C. Keep the head of the bed elevated at all times.
- D. Practice therapeutic communication.
Correct Answer: A
Rationale: Strict intake and output monitoring detects early renal dysfunction, preventing MODS progression. Pain control, head elevation, and communication are less specific.
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.
The female client is homeless and pregnant. The client supports an IV drug habit by prostitution. Which data would be considered antecedents (risk factor) for becoming HIV positive? Select all that apply.
- A. The client is pregnant.
- B. The client is an intravenous drug abuser.
- C. The client has multiple sexual partners.
- D. The client does not have available health care.
- E. The client does not have adequate bathroom facilities.
- F. The client spends her money on nonessential items.
Correct Answer: B,C,D
Rationale: IV drug use, multiple sexual partners, and lack of healthcare increase HIV risk. Pregnancy, bathroom facilities, and spending are not direct risk factors.
The nurse is developing a care plan for a client diagnosed with SLE. Which goal is priority for this client?
- A. The client will maintain reproductive ability.
- B. The client will verbalize feelings of body-image changes.
- C. The client will have no deterioration of organ function.
- D. The client’s skin will remain intact and have no irritation.
Correct Answer: C
Rationale: Preventing organ deterioration is critical in SLE to avoid life-threatening complications. Reproduction, body image, and skin integrity are secondary.
The client has had an anaphylactic reaction to insect venom, a bee sting. Which discharge instruction should the nurse discuss with the client?
- A. Take a corticosteroid dose pack when stung by a bee.
- B. Take antihistamines prior to outdoor activities.
- C. Use a cromolyn sodium (Intal) inhaler prophylactically.
- D. Carry a bee sting kit, especially when going outside.
Correct Answer: D
Rationale: Carrying a bee sting kit (EpiPen) is critical for managing future anaphylaxis. Steroids, antihistamines, and cromolyn are less effective prophylactically.