Which statement by the female client diagnosed with myasthenia gravis indicates the client needs more discharge teaching?
- A. I will not have any menstrual cycles because of this disease.
- B. I should avoid people who have respiratory infections.
- C. I should not take a hot bath or swim in cold water.
- D. I will drink at least 2,500 mL of water a day.
Correct Answer: A
Rationale: Myasthenia gravis does not affect menstrual cycles, indicating a need for teaching. Avoiding infections, temperature extremes, and hydration are correct.
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Which interventions should the nurse discuss with the female client who is positive for human immunodeficiency virus (HIV)? Select all that apply.
- A. Recommend the client not to engage in unprotected sexual activity.
- B. Instruct the client not to inform past sexual partners of HIV status.
- C. Tell the client to not donate blood, organs, or tissues.
- D. Suggest the client not get pregnant.
- E. Explain the client does not have to tell health-care personnel of HIV status.
Correct Answer: A,C,D
Rationale: Unprotected sex, blood/organ donation, and pregnancy risk HIV transmission or complications. Partner notification and informing healthcare personnel are recommended.
The client diagnosed with Guillain-Barré syndrome is on a ventilator. Which intervention will assist the client to communicate with the nursing staff?
- A. Provide an erase slate board for the client to write on.
- B. Instruct the client to blink once for 'no' and twice for 'yes.'
- C. Refer to a speech therapist to help with communication.
- D. Leave the call light within easy reach of the client.
Correct Answer: B
Rationale: Blinking (once for no, twice for yes) is a simple communication method for a ventilated client with paralysis. Writing, speech therapy, and call light access are less feasible.
The client diagnosed with a bee sting allergy is being discharged from the emergency department. Which priority discharge instruction should be taught to the client?
- A. Demonstrate how to use an EpiPen, an adrenergic agonist.
- B. Teach the client to never go outdoors in the spring and summer.
- C. Have the client buy diphenhydramine over the counter to use when stung.
- D. Discuss wearing a Medic Alert bracelet when going outside.
Correct Answer: A
Rationale: EpiPen use is critical for managing anaphylaxis in bee sting allergies. Avoiding outdoors is impractical, diphenhydramine is secondary, and bracelets are supportive.
The 20-year-old female client diagnosed with advanced unremitting RA is being admitted to receive a regimen of immunosuppressive medications. Which question should the nurse ask during the admission process regarding the medications?
- A. Are you sexually active, and, if so, are you using birth control?
- B. Have you discussed taking these drugs with your parents?
- C. Which arm do you prefer to have an IV in for four (4) days?
- D. Have you signed an informed consent for investigational drugs?
Correct Answer: A
Rationale: Immunosuppressants are teratogenic, making contraception critical. Parental discussion, IV preference, and investigational consent are less relevant.
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.
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