Nokea
Which statement by the client supports the diagnosis of Guillain-Barré syndrome?
- A. I just returned from a short trip to Japan.
- B. I had a really bad cold just a few weeks ago.
- C. I think one of the people I work with had this.
- D. I have been taking some herbs for more than a year.
Correct Answer: B
Rationale: A recent viral infection (e.g., cold) is a common trigger for Guillain-Barré syndrome. Travel, coworker illness, and herbs are less relevant.
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The client diagnosed with Systemic Response Inflammatory Syndrome (SIRS) asks the nurse what the diagnosis means. Which is the nurse's best response?
- A. SIRS is a localized response to major trauma that has occurred within the last three (3) months.
- B. SIRS is a syndrome of potential responses to illness that has an optimum prognosis.
- C. SIRS is a respiratory response to the client having had a myocardial infarction or pneumonia.
- D. SIRS is a systemic response to a variety of insults, including infection, ischemia, and injury.
Correct Answer: D
Rationale: SIRS is a systemic response to insults like infection or trauma. It is not localized, has variable prognosis, and is not solely respiratory.
The wife of a client diagnosed with myasthenia gravis is crying and shares with the nurse she just doesn't know what to do. Which response is the best action by the nurse?
- A. Discuss the Myasthenia Foundation with the client's wife.
- B. Refer the client to a local myasthenia gravis support group.
- C. Ask the client's wife if she would like to talk to a counselor.
- D. Sit down and allow the wife to ventilate her feelings to the nurse.
Correct Answer: D
Rationale: Allowing the wife to ventilate feelings is therapeutic, addressing immediate emotional distress. Foundation discussion, support groups, and counseling are secondary.
The client diagnosed with an acute exacerbation of multiple sclerosis is placed on high-dose intravenous injections of corticosteroid medication. Which nursing intervention should be implemented?
- A. Discuss discontinuing the proton pump inhibitor with the HCP.
- B. Hold the medication until after all cultures have been obtained.
- C. Monitor the client's serum blood glucose levels frequently.
- D. Provide supplemental dietary sodium with the client's meals.
Correct Answer: C
Rationale: High-dose corticosteroids can cause hyperglycemia, requiring frequent glucose monitoring. Proton pump inhibitors are unrelated, cultures are not needed, and sodium supplementation is unnecessary.
The client newly diagnosed with multiple sclerosis (MS) states, 'I don't understand how I got multiple sclerosis. Is it genetic?' On which statement should the nurse base the response?
- A. Genetics may play a role in susceptibility to MS, but the disease may be caused by a virus.
- B. There is no evidence suggesting there is any chromosomal involvement in developing MS.
- C. Multiple sclerosis is caused by a recessive gene, so both parents had to have the gene for the client to get MS.
- D. Multiple sclerosis is caused by an autosomal dominant gene on the Y chromosome, so only fathers can pass it on.
Correct Answer: A
Rationale: MS has a genetic susceptibility component (e.g., HLA genes), but environmental factors like viral infections may trigger it. There is chromosomal involvement, MS is not purely recessive or dominant, and it is not Y-linked.
The nurse enters the room of a female client diagnosed with SLE and finds the client crying. Which statement is the most therapeutic response?
- A. I know you are upset, but stress makes the SLE worse.
- B. Please explain to me why you are crying.
- C. I recommend going to an SLE support group.
- D. I see you are crying. We can talk if you would like.
Correct Answer: D
Rationale: Acknowledging crying and offering to talk is therapeutic, encouraging emotional expression. Linking stress to SLE, demanding explanations, or suggesting groups are less supportive.