The following scenario applies to the next 6 items
The nurse in the intensive care unit (ICU) is caring for a 59-year-old female client
Item 2 of 6
Admission Note
Nurses' Notes
Physician Orders
1450 - Client was admitted directly from the primary health care physician's office for a severe exacerbation of systemic lupus erythematosus (SLE). The client was being treated outpatient with corticosteroids but was not responding. Reported intermittent chest pain at the physician's office and became pale and
Diaphoretic. The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
• The client was directly admitted to the intensive care unit for observation and medical management. • Cardiac consultation has been placed, and laboratory work is pending. The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension
Which of the following issues is the client at risk of developing? Select all that apply.
Rationale:
The client is at risk of developing cardiac tamponade, cardiogenic shock, stroke, and acute coronary syndrome.
The client's severe exacerbation of systemic lupus erythematosus, combined with reported chest pain and a history of pulmonary hypertension, increases susceptibility to these serious cardiac and vascular complications, necessitating close monitoring and intervention in the ICU setting.
D: pneumothorax This complication is primarily associated with trauma or mechanical ventilation, neither of which are indicated in this patient's admission context.
B: cardiogenic shock The client’s normal troponin levels and ECG suggest no acute cardiac event, reducing the likelihood of cardiogenic shock despite her critical condition.
C: stroke While the client's history of systemic lupus erythematosus could increase stroke risk, there’s no immediate evidence of neurological deficits or complications at this time.
E: acute coronary syndrome Although the client presents with chest pain, the absence of ST-elevations and normal troponin levels indicates that acute coronary syndrome is not currently developing.
The intensive care unit (ICU) nurse is preparing to admit a client with Guillain-Barre syndrome. Which of the following items is essential for the nurse to have at the client's bedside?
Rationale:
Oral intubation equipment is essential for the nurse to have at the client's bedside. Guillain-Barre syndrome can lead to respiratory failure due to progressive muscle weakness, necessitating immediate airway management and ventilation support. Having this equipment readily available ensures timely intervention, which is crucial in an ICU setting to prevent complications and stabilize the patient's condition.
A: Blood pressure cuff Monitoring blood pressure is important, but it does not address the immediate risk of respiratory failure associated with Guillain-Barre syndrome, making it less critical than intubation equipment.
B: Pulse oximeter While monitoring oxygen saturation is necessary, it does not provide the immediate airway management required for a patient experiencing respiratory distress due to Guillain-Barre syndrome.
D: Arterial blood gas (ABG) supplies Although ABG supplies are useful for assessing respiratory function, they do not facilitate immediate intervention, which is vital for a patient whose airway may need protection.
A client in the medical ward developed sudden hypotension, difficulty breathing, and cyanosis shortly after receiving an intravenous penicillin infusion. Based on the nurses' understanding of anaphylactic reactions, what can the nurse conclude is the cause of this reaction?
Rationale:
The client was previously exposed to penicillin, enabling their body to produce antibodies. This prior exposure leads to a hypersensitive immune response upon subsequent administration, triggering the severe symptoms observed during the infusion.
A: Potent antibodies formed when the antibiotic was infused into the client during this infusion. Antibodies cannot form instantaneously during an infusion; they require prior exposure to develop.
C: The client developed passive immunity to penicillin. Passive immunity involves receiving antibodies from another source, not from the body’s response to an infusion of penicillin.
D: Atopic sensitization occurred. Atopic sensitization refers to a non-IgE mediated response to allergens, which does not align with the immediate anaphylactic reaction demonstrated by the client.
The following scenario applies to the next 6 items
The nurse in the intensive care unit (ICU) is caring for a 59-year-old female client
Item 6 of 6
Admission Note
Nurses' Notes
Physician Orders
1450 - Client was admitted directly from the primary health care physician's office for a severe exacerbation of systemic lupus erythematosus (SLE). The client was being treated outpatient with corticosteroids but was not responding. Reported intermittent chest pain at the physician's office and became pale and
Diaphoretic. The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
• The client was directly admitted to the intensive care unit for observation and medical management. • Cardiac consultation has been placed, and laboratory work is pending. The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension
The nurse teaches the client self-care practices for systemic lupus erythematosus (SLE). Which two (2) client statements indicate effective understanding?
Rationale:
B: I should wear long sleeves and a large-brimmed hat when outdoors. This statement demonstrates effective understanding as it emphasizes the importance of sun protection for individuals with systemic lupus erythematosus (SLE), who are particularly sensitive to UV rays.
A: I should limit my exposure to direct sunlight to 45 continuous minutes each day. This recommendation lacks specificity regarding sun exposure, failing to emphasize the importance of complete avoidance of direct sunlight for SLE patients.
C: I should wash my skin with an antibacterial soap. While skin care is important, antibacterial soap is not specifically recommended for SLE patients and may not address their unique dermatological needs.
E: I should refrain from receiving any vaccine. This statement is misleading; some vaccines are safe and recommended for SLE patients, so blanket avoidance is not appropriate for their care.
The following scenario applies to the next 6 items
The nurse in the intensive care unit (ICU) is caring for a 59-year-old female client
Item 3 of 6
Admission Note
Nurses' Notes
Physician Orders
1450 - Client was admitted directly from the primary health care physician's office for a severe exacerbation of systemic lupus erythematosus (SLE). The client was being treated outpatient with corticosteroids but was not responding. Reported intermittent chest pain at the physician's office and became pale and
Diaphoretic. The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
• The client was directly admitted to the intensive care unit for observation and medical management. • Cardiac consultation has been placed, and laboratory work is pending. The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension
The client is most likely experiencing ………………..
Rationale:
The client is most likely experiencing cardiac tamponade.
The client's symptoms, such as pale skin, diaphoresis, and chest pain, alongside her history of systemic lupus erythematosus, suggest fluid accumulation around the heart, characteristic of cardiac tamponade. The absence of ST-elevations on the ECG further indicates that a heart attack is less likely, reinforcing this diagnosis.
A: acute coronary syndrome Intermittent chest pain alone does not confirm acute coronary syndrome, especially with normal ECG results and no elevated troponin levels, indicating a different underlying issue.
B: pneumothorax The absence of respiratory distress or abnormal lung sounds in the notes suggests that pneumothorax is not a likely diagnosis for this client’s current condition.
The nurse suspects the client is experiencing ………………… which is classified as a(n) ……………………………
Rationale:
Erythematosus (SLE) is classified as an autoimmune disorder. This diagnosis is supported by the presence of symptoms that indicate the immune system is attacking the body's own tissues, characteristic of autoimmune conditions.
A: rheumatoid arthritis An autoimmune condition primarily affecting joints, but does not share the systemic manifestations typical of SLE, which can impact multiple organ systems.
B: multiple sclerosis This condition primarily affects the central nervous system and does not align with the symptoms or classification of SLE as an autoimmune disorder.
D: anaphylaxis A severe allergic reaction that is not classified as an autoimmune disorder, as it does not involve the immune system attacking the body’s own tissues.
E: myasthenia gravis While it is an autoimmune disorder, the specific symptoms and systemic involvement of SLE differentiate it from myasthenia gravis, which primarily affects neuromuscular function.
F: Hypersensitivity disorder This term encompasses a range of allergic reactions, which do not accurately describe SLE, known for its complex autoimmune pathology and varied clinical presentation.
The nurse in the emergency department (ED) is assessing a client with anaphylactic shock. Which of the following findings would support a diagnosis of anaphylactic shock?
Rationale:
Cutaneous cyanosis and pruritus are findings that support a diagnosis of anaphylactic shock. These symptoms indicate severe allergic reactions, which can lead to compromised oxygenation and skin reactions, characteristic of anaphylaxis.
A: hypertension High blood pressure is typically not associated with anaphylactic shock; instead, hypotension is more common due to vasodilation and fluid loss during this acute allergic reaction.
B: crackles (rales) in the lung fields While lung crackles may indicate fluid overload or pulmonary issues, they do not specifically support the diagnosis of anaphylactic shock, which is primarily characterized by systemic reactions.
D: pruritus Pruritus, or intense itching, is a hallmark symptom of anaphylaxis, resulting from histamine release during allergic reactions, thus supporting the diagnosis alongside cutaneous cyanosis.
The nurse is caring for a client with Guillain-Barré syndrome (GBS). The nurse plans on taking which priority action?
Rationale:
A: Assessing respiratory status frequently. Frequent assessment of respiratory status is critical in Guillain-Barré syndrome due to the risk of respiratory muscle weakness, which can lead to respiratory failure and necessitate prompt intervention.
B: Administering intravenous immunoglobulin (IVIG) as prescribed. While IVIG is an important treatment for GBS, immediate respiratory assessment takes precedence to ensure the client’s airway is secure and functioning.
C: Providing passive range of motion exercises to maintain joint mobility. Although beneficial for joint health, this action does not address the immediate risk of respiratory compromise, which is crucial in GBS management.
D: Monitoring for autonomic dysreflexia. This condition is not typically associated with Guillain-Barré syndrome, making it less relevant in prioritizing care, especially when respiratory issues are more pressing.
The following scenario applies to the next 6 items
The nurse in the intensive care unit (ICU) is caring for a 59-year-old female client
Item 4 of 6
Admission Note
Nurses' Notes
Physician Orders
1450 - Client was admitted directly from the primary health care physician's office for a severe exacerbation of systemic lupus erythematosus (SLE). The client was being treated outpatient with corticosteroids but was not responding. Reported intermittent chest pain at the physician's office and became pale and
Diaphoretic. The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
• The client was directly admitted to the intensive care unit for observation and medical management. • Cardiac consultation has been placed, and laboratory work is pending. The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension
For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client experiencing cardiac tamponade.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Prepare the client for an immediate thoracentesis
B
Obtain a prescription for an isotonic fluid bolus
C
Perform frequent vital sign collection
D
Obtain a prescription for intravenous furosemide
Rationale:
C: Perform frequent vital sign collection. Continuous monitoring of vital signs is crucial for clients with cardiac tamponade, as it helps assess hemodynamic stability and detect any changes that may indicate worsening conditions.
A: Prepare the client for an immediate thoracentesis. Thoracentesis is not indicated since the client is not diagnosed with cardiac tamponade; she requires observation and medical management instead.
B: Obtain a prescription for an isotonic fluid bolus. Fluid resuscitation is not appropriate, as the client’s condition does not indicate hypovolemia and could potentially worsen her overall status.
D: Obtain a prescription for intravenous furosemide. Administering furosemide is unsuitable, as the client does not exhibit fluid overload symptoms; management focuses on her underlying lupus exacerbation and cardiac consultation.
The following scenario applies to the next 6 items
The nurse in the intensive care unit (ICU) is caring for a 59-year-old female client
Item 5 of 6
Admission Note
Nurses' Notes
Physician Orders
1450 - Client was admitted directly from the primary health care physician's office for a severe exacerbation of systemic lupus erythematosus (SLE). The client was being treated outpatient with corticosteroids but was not responding. Reported intermittent chest pain at the physician's office and became pale and
Diaphoretic. The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
• The client was directly admitted to the intensive care unit for observation and medical management. • Cardiac consultation has been placed, and laboratory work is pending. The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension
The nurse prepares the client for an emergent pericardiocentesis and it is essential to have …………….. at the bedside. During the procedure, it is a priority for the nurse to monitor the client's ………….
Rationale:
A: a bottle of sterile water
Having sterile water at the bedside does not address the immediate risks associated with pericardiocentesis. The primary concern during this procedure is the potential for cardiac complications.
C: positive pressure ventilation
While positive pressure ventilation may be necessary in certain emergencies, it is not specifically required for the pericardiocentesis procedure itself, which focuses on fluid removal from the pericardial space.
D: urinary output
Monitoring urinary output is not relevant during pericardiocentesis. The priority lies in assessing cardiac function and rhythm, as complications can arise from fluid removal.
F: Glasgow coma scale
The Glasgow coma scale measures consciousness levels and is not pertinent to the pericardiocentesis procedure. The primary focus should be on the client's cardiac rhythm and potential complications.
The following scenario applies to the next 6 items
The nurse in the intensive care unit (ICU) is caring for a 59-year-old female client
Item 1 of 6
Admission Note
Nurses' Notes
Physician Orders
1450 - Client was admitted directly from the primary health care physician's office for a severe exacerbation of systemic lupus erythematosus (SLE). The client was being treated outpatient with corticosteroids but was not responding. Reported intermittent chest pain at the physician's office and became pale and
Diaphoretic. The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
• The client was directly admitted to the intensive care unit for observation and medical management. • Cardiac consultation has been placed, and laboratory work is pending. The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension
Which of the following assessment findings require immediate follow-up? Select all that apply.
Rationale:
Assessment findings A, B, D, F, and G require immediate follow-up. These findings pertain to critical systems—respiratory and cardiovascular—that could indicate worsening conditions, especially given the client’s history of systemic lupus erythematosus and acute symptoms.
C: temperature Elevated or lowered body temperature may indicate infection or other issues, but it is less critical than respiratory and cardiovascular assessments in this acute scenario.
E: butterfly-shaped rash on face This rash is characteristic of lupus but does not indicate an immediate life-threatening issue requiring urgent intervention compared to other findings.
The nurse is planning a staff development conference about anaphylaxis. Which of the following information should the nurse include?
Rationale:
0.9% saline should be infused once vascular access is established. This is vital for maintaining blood pressure and hydration during anaphylaxis, as it supports fluid resuscitation and stabilizes the patient’s condition effectively.
B: The initial treatment is intravenous diphenhydramine. Diphenhydramine is not the first-line treatment for anaphylaxis; epinephrine is the primary medication to address severe allergic reactions.
C: The client should carry a prefilled syringe of hydrocortisone. Hydrocortisone is not typically carried for immediate anaphylaxis treatment; instead, epinephrine is the essential medication for emergency situations.
D: If shock occurs, the client should be positioned in reverse Trendelenburg. This positioning is not standard for anaphylactic shock; lying flat or in a supine position is generally recommended to optimize circulation.
The nurse in the outpatient clinic is assessing a client with systemic lupus erythematosus (SLE). Which laboratory data is essential for the nurse to monitor to determine if the client is experiencing a complication?
Rationale:
Urine analysis is essential for the nurse to monitor complications in clients with systemic lupus erythematosus (SLE). It helps detect proteinuria and hematuria, which indicate potential kidney involvement, a common complication of SLE.
B: Hemoglobin A1C (HbA1C) This test primarily assesses long-term glucose control in diabetic patients and does not provide relevant information about SLE complications.
C: Thyroid-stimulating hormone (TSH) TSH levels evaluate thyroid function and are not directly related to monitoring systemic lupus erythematosus complications, limiting their relevance in this context.
D: Ammonia Ammonia levels are primarily associated with liver function and metabolic conditions, lacking direct connection to the complications associated with systemic lupus erythematosus.
You are caring for a patient with Raynaud's disease who has intractable pain. The patient is scheduled to undergo surgical interruption of pain conduction pathways to improve vascular blood supply as well as eliminate vasospasm and pain. Which type of surgery is the patient most likely to undergo?
Rationale:
D: Sympathectomy. This procedure involves cutting sympathetic nerves to alleviate pain and improve blood flow, making it suitable for patients with Raynaud's disease experiencing severe pain and vascular issues.
A: Cordotomy. This technique primarily targets pain pathways in the spinal cord, which may not effectively address the vascular problems associated with Raynaud's disease.
B: Rhizotomy. Aimed at severing nerve roots to relieve pain, it doesn't specifically address the sympathetic nervous system's role in vasospasm and blood flow issues.
C: Neurectomy. While this involves removing specific nerves to reduce pain, it lacks the direct impact on sympathetic nerves crucial for managing Raynaud's disease symptoms effectively.
The nurse is assessing a client who has Raynaud's phenomenon. Which of the following would be an expected finding?
Rationale:
Digit color changes are an expected finding in a client with Raynaud's phenomenon, as the condition is characterized by episodes of vasospasm leading to alterations in skin coloration, typically resulting in pallor, cyanosis, and then redness upon rewarming.
B: Flapping hand tremor. This symptom indicates a different neurological condition, such as essential tremor or Parkinson's disease, rather than being associated with Raynaud's phenomenon.
C: Painless skin ulcers. While ulcers can occur in various conditions, they are not a typical manifestation of Raynaud's phenomenon, which primarily involves transient color changes in digits.
D: Janeway lesions. These lesions are indicative of infective endocarditis and not related to Raynaud's phenomenon, which focuses on intermittent vascular changes rather than structural skin abnormalities.
The nurse is assessing a client who has suspected Raynaud phenomenon/disease. Which of the following findings would support a diagnosis of Raynaud phenomenon/disease?
Rationale:
Painful vasospasms are characteristic of Raynaud phenomenon/disease, indicating that blood vessels constrict excessively in response to cold or stress, leading to discomfort and color changes in extremities.
A: unilateral swelling of the leg This finding does not align with Raynaud phenomenon, as it typically involves bilateral symptoms affecting fingers and toes, rather than localized swelling in one leg.
C: crepitus of the joints Crepitus, the grating sensation in joints, is unrelated to Raynaud phenomenon and suggests joint or cartilage issues instead of the vascular symptoms associated with this condition.
D: claudication in feet and lower extremities Claudication indicates inadequate blood flow during activity, which differs from Raynaud phenomenon, where symptoms occur at rest or with temperature changes rather than during exertion.
The nurse is discussing the underlying mechanism of psoriasis with a client recently diagnosed with the condition. The nurse explains that psoriasis is primarily associated with?
Rationale:
Overactivity of the immune system targeting healthy skin cells. This explanation highlights that psoriasis arises from an aberrant immune response, where the immune system mistakenly attacks normal skin cells, leading to inflammation and rapid skin cell turnover.
B: deficiency of T lymphocytes leading to skin inflammation. This suggests a lack of immune response, which contradicts psoriasis being driven by an overactive immune system rather than insufficient T lymphocytes.
C: impaired production of melanocytes causing skin discoloration. While melanocytes impact skin color, psoriasis primarily involves immune system dysfunction rather than issues related to the production of these pigment-producing cells.
D: excessive sebum production resulting in follicular plugging. This describes acne more accurately; psoriasis is characterized by immune-mediated processes rather than problems with sebum production or hair follicle blockage.
The client recently diagnosed with SLE asks the nurse, 'What is SLE and how did I get it?' Which statement best explains the scientific rationale for the nurse's response?
Rationale:
SLE is an autoimmune disease that may have a genetic or hormonal component. This explanation encompasses the complexities of the condition, highlighting the interplay of immune system dysfunction and potential hereditary factors contributing to its development.
A: SLE occurs because the kidneys do not filter antibodies from the blood. This oversimplifies the disease, as SLE involves systemic immune dysregulation rather than solely kidney filtration issues.
B: SLE occurs after a viral illness as a result of damage to the endocrine system. This inaccurately suggests a direct causative link between viral infections and endocrine damage, which lacks substantial scientific backing.
C: There is no known identifiable reason for a client to develop SLE. While the exact causes remain unclear, this statement disregards the recognized genetic and hormonal influences associated with SLE.
The client diagnosed with AIDS is angry and yells at everyone entering the room, and none of the staff members wants to care for the client. Which intervention is most appropriate for the nurse manager to use in resolving this situation?
Rationale:
Call a team meeting and discuss options with the staff.
This approach fosters open communication among team members, allowing for collaborative problem-solving. It encourages the staff to express their feelings and explore strategies to manage the client's behavior collectively, promoting a supportive work environment.
A: Assign a different nurse every shift to the client. This strategy risks inconsistency in care and may exacerbate the client's feelings of abandonment, worsening their anger towards the staff.
B: Ask the HCP to tell the client not to yell at the staff. Relying solely on the HCP could create further conflict, as it places blame on external authority rather than fostering teamwork and understanding.
D: Tell one (1) staff member to care for the client a week at a time. This approach may lead to burnout for that staff member and does not address the underlying issues of the client's anger.
Which surgical procedure should the nurse anticipate the client with myasthenia gravis undergoing to help prevent the signs/symptoms of the disease process?
Rationale:
C: A thymectomy. This procedure involves the surgical removal of the thymus gland, which plays a significant role in the immune system and is often linked to the exacerbation of myasthenia gravis symptoms. By reducing the thymus tissue, the surgery can help alleviate the disease's manifestations and improve muscle strength for affected individuals.
A: There is no surgical option. Surgical intervention is indeed available and often necessary for managing myasthenia gravis, particularly through thymectomy, which directly addresses the underlying pathophysiology.
B: A transsphenoidal hypophysectomy. This procedure targets the pituitary gland and is not relevant to myasthenia gravis, as it does not address the autoimmune aspects or thymus involvement specific to this disorder.
D: An adrenalectomy. Removal of the adrenal glands pertains to hormonal issues and does not relate to the immune dysfunction present in myasthenia gravis, making it unsuitable for symptom management in this condition.
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?
Rationale:
Abstinence is the only guarantee of not becoming infected with sexually transmitted HIV. This emphasizes that refraining from sexual activity is the sole method that completely eliminates the risk of HIV transmission, crucial for educating adolescents about safe practices.
A: Females taking birth control pills are protected from becoming infected with HIV. Birth control pills do not provide protection against HIV; they solely prevent pregnancy, leaving individuals vulnerable to sexually transmitted infections.
B: Protected sex is no longer an issue because there is a vaccine for the HIV virus. Currently, there is no vaccine available for HIV, making protection through safe practices still essential for preventing transmission.
C: Adolescents with a normal immune system are not at risk for developing AIDS. A normal immune system does not shield adolescents from HIV infection; anyone can contract the virus regardless of their immune status.
The 30-year-old female client is admitted with complaints of numbness, tingling, a crawling sensation affecting the extremities, and double vision which has occurred two (2) times in the month. Which question is most important for the nurse to ask the client?
Rationale:
C: Do you get tired easily and sometimes have problems swallowing? This question addresses potential symptoms of a neurological condition like multiple sclerosis, which aligns with the client's complaints of numbness, tingling, and double vision.
A: Have you experienced any difficulty with your menstrual cycle? While important, menstrual cycle issues are less relevant to the immediate neurological symptoms presented by the client.
B: Have you noticed a rash across the bridge of your nose? This question pertains to conditions like lupus, which do not directly relate to the client's neurological complaints of double vision and extremity sensations.
D: Are you taking birth control pills to prevent conception? Though relevant to overall health, this question does not connect directly to the neurological symptoms the client is experiencing.
The nurse enters the room of a client diagnosed with acute exacerbation of multiple sclerosis and finds the client crying. Which statement is the most therapeutic response for the nurse to make?
Rationale:
You seem upset. I will sit down and we can talk for awhile.
This response demonstrates empathy and encourages open communication, allowing the client to express their feelings. It fosters a supportive environment and builds trust, which is essential in therapeutic relationships, particularly during emotional distress associated with health challenges like multiple sclerosis.
A: Why are you crying? The medication will help the disease. This approach may feel dismissive, focusing on medication rather than acknowledging the client's emotional state, potentially stifling further communication.
C: Multiple sclerosis is a disease that has good times and bad times. This statement lacks direct engagement with the client’s feelings, making it less supportive and failing to address their immediate emotional distress.
D: I will have the chaplain come and stay with you for a while. While offering spiritual support can be beneficial, this response may bypass the opportunity for immediate emotional connection and understanding.
The client diagnosed with myasthenia gravis is admitted with an acute exacerbation. Which interventions should the nurse implement? Select all that apply.
Rationale:
Assist the client to turn and cough every two (2) hours, place the client in a high or semi-Fowler's position, assess the client's pulse oximeter reading every shift, and plan meals to promote medication effectiveness.
The interventions listed enhance respiratory function, optimize airway clearance, and support medication efficacy in managing myasthenia gravis exacerbations, ensuring the client’s safety and comfort during acute episodes.
C: Assess the client's pulse oximeter reading every shift. While monitoring oxygen levels is vital, assessing every shift may not suffice during acute exacerbations requiring more frequent checks.
D: Plan meals to promote medication effectiveness. Although medication timing with meals is crucial, this option lacks direct relevance to immediate interventions needed during an acute exacerbation of myasthenia gravis.
E: Monitor the client's serum anticholinesterase levels. Serum levels are significant for long-term management but do not address the acute symptoms and immediate care required during an exacerbation.
The client in the HCP's office has a red, raised rash covering the forearms, neck, and face and is experiencing extreme itching which is diagnosed as an allergic reaction to poison ivy. Which discharge instructions should the nurse teach?
Rationale:
C: Explain how to take a steroid dose pack. This is the appropriate instruction as corticosteroids can effectively reduce inflammation and alleviate severe itching associated with allergic reactions, providing the necessary relief for the client's symptoms.
A: Tell the client never to scratch the rash. While scratching should be avoided to prevent further irritation or infection, this advice does not address the underlying allergic reaction requiring treatment.
B: Instruct the client in administering IM Benadryl. Intramuscular administration of Benadryl is unnecessary for this situation, as oral antihistamines are typically sufficient for managing mild allergic reactions like those from poison ivy.
D: Have the client wear shirts with long sleeves and high necks. This preventative measure may help avoid future exposure but does not provide immediate relief or treatment for the current allergic reaction symptoms.
The client is being evaluated to rule out myasthenia gravis and being administered the Tensilon (edrophonium chloride) test. Which response to the test indicates the client has myasthenia gravis?
Rationale:
The client shows a marked improvement of muscle strength.
This response indicates myasthenia gravis because the administration of Tensilon inhibits acetylcholinesterase, leading to increased acetylcholine at the neuromuscular junction, enhancing muscle contraction and strength temporarily in affected individuals.
A: The client has no apparent change in the assessment data. This response suggests no effect from the Tensilon test, which does not align with the expected outcome in myasthenia gravis.
B: There is increased amplitude of electrical stimulation in the muscle. Increased amplitude does not specifically indicate myasthenia gravis, as it may suggest other neuromuscular conditions or normal muscle response.
C: The circulating acetylcholine receptor antibodies are decreased. A decrease in these antibodies does not correspond with myasthenia gravis diagnosis, as elevated levels are typically present in affected patients.
The client diagnosed with myasthenia gravis is being discharged home. Which intervention has priority when teaching the client's significant others?
Rationale:
A: Discuss ways to help prevent choking episodes.
Prioritizing choking prevention is crucial for clients with myasthenia gravis, as their muscle weakness can impair swallowing. Educating significant others on strategies to minimize choking risks directly addresses a life-threatening concern, ensuring safer mealtime experiences and enhancing overall health management at home.
B: Explain how to care for a client on a ventilator.
Ventilator care is not immediately relevant since most clients with myasthenia gravis do not require mechanical ventilation at home, making this intervention less critical for discharge planning.
C: Teach how to perform passive range-of-motion exercises.
While passive range-of-motion exercises are beneficial, they do not address the immediate risk of choking that clients with myasthenia gravis face, making this less urgent than discussing choking prevention.
D: Demonstrate how to care for the client's feeding tube.
Feeding tube care is important but secondary to immediate safety concerns like choking. Prioritizing choking prevention ensures clients can safely consume food and liquids while at home.
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?
Rationale:
D: Sit down and allow the wife to ventilate her feelings to the nurse.
Providing a supportive environment for the wife to express her emotions is crucial. Active listening fosters trust, encourages her to process her feelings, and demonstrates empathy, which can alleviate her distress and help her cope with her husband's condition.
A: Discuss the Myasthenia Foundation with the client's wife.
While informative, this approach does not prioritize the wife's immediate emotional needs or provide the empathetic support she currently requires during a distressing moment.
B: Refer the client to a local myasthenia gravis support group.
Referral to a support group may not directly address the wife's immediate emotional turmoil and might feel impersonal, as she needs immediate emotional validation rather than information.
C: Ask the client's wife if she would like to talk to a counselor.
Suggesting a counselor may seem dismissive of her current emotional need, as the wife is seeking immediate, compassionate support rather than being directed to another resource.
The client diagnosed with RA who has been prescribed etanercept, a tumor necrosis factor alpha inhibitor, shows marked improvement. Which instruction regarding the use of this medication should the nurse teach?
Rationale:
B: Continue to have checkups and laboratory work while taking the medication. Regular monitoring is essential to assess the treatment's effectiveness and detect any potential side effects or complications associated with etanercept, ensuring patient safety and optimal therapeutic outcomes.
A: Explain the medication loses its efficacy after a few months. This statement lacks evidence, as many patients experience sustained benefits over extended periods with continued etanercept therapy, given appropriate monitoring.
C: Have yearly magnetic resonance imaging to follow the progress. MRI is not routinely required for monitoring the effectiveness of etanercept; clinical assessments and laboratory tests are usually sufficient to evaluate treatment response.
D: Discuss the drug is taken for three (3) weeks and then stopped for a week. Etanercept is typically administered on a consistent schedule, rather than a cyclical regimen, to maintain effective therapeutic levels in the body.
The nurse on a medical floor is caring for clients diagnosed with AIDS. Which client should be seen first?
Rationale:
The client whose vital signs are T 99.9°F, P 101, R 26, and BP 110/68 should be seen first. This client exhibits signs of potential infection or respiratory distress, indicating an urgent need for assessment and intervention to prevent further complications in their already compromised health status.
A: The client who has flushed, warm skin with tented turgor suggests dehydration but does not present immediate life-threatening symptoms compared to the other clients' more critical signs.
B: The client who states the staff ignores the call light indicates a concern about communication and responsiveness, yet this issue does not require immediate medical attention over others' deteriorating conditions.
D: The client who is unable to provide a sputum specimen may need support with testing, but this situation is less critical than addressing the vital signs indicating potential instability in another patient.
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?
Rationale:
Are you sexually active, and, if so, are you using birth control? This question is essential as immunosuppressive medications can pose significant risks during pregnancy, and ensuring effective contraception is crucial for the client's safety and health.
B: Have you discussed taking these drugs with your parents? While family involvement may be beneficial, it does not directly address the immediate health concerns related to medication and sexual activity.
C: Which arm do you prefer to have an IV in for four (4) days? This inquiry focuses on logistical preferences rather than crucial health implications linked to medication use and potential pregnancy.
D: Have you signed an informed consent for investigational drugs? This question pertains more to research protocols rather than the critical issue of ensuring safe medication use in relation to sexual health.
The client is highly allergic to insect venom and is prescribed venom immunotherapy. Which statement is the scientific rationale for this treatment?
Rationale:
Immunotherapy is effective in preventing anaphylaxis following a future sting. This treatment works by gradually desensitizing the immune system to the venom, significantly reducing the risk of severe allergic reactions over time.
B: Immunotherapy will prevent all future insect stings from harming the client. While it reduces the severity of reactions, it does not eliminate the risk of stings or their effects entirely.
C: This therapy will cure the client from having any allergic reactions in the future. Immunotherapy can diminish allergic responses but does not guarantee complete immunity from future reactions to insect venom.
D: This therapy is experimental and should not be undertaken by the client. Venom immunotherapy is an established and proven treatment for insect venom allergies, widely recognized for its efficacy and safety.
The nurse and a licensed practical nurse are caring for clients in a rheumatologist's office. Which task can the nurse assign to the licensed practical nurse?
Rationale:
C: Demonstrate how to use clothing equipped with Velcro fasteners. This task aligns with the licensed practical nurse's scope of practice, enabling them to provide education and support to clients regarding adaptive clothing solutions that enhance daily living.
A: Administer methotrexate, an antineoplastic medication, IV. This procedure requires specialized training and is typically within the registered nurse's scope, not the licensed practical nurse's responsibilities.
B: Assess the lung sounds of a client with RA who is coughing. Assessment of lung sounds is a complex task that should be performed by a registered nurse to ensure accurate clinical evaluation.
D: Discuss methods of birth control compatible with treatment medications. This topic involves comprehensive patient education and clinical judgment, which are generally expected to be handled by registered nurses.
The nurse in the holding area of the operating room is assessing the client prior to surgery. Which information warrants immediate intervention by the nurse?
Rationale:
The client is allergic to iodine and does not have an allergy bracelet. This information is critical as it poses a significant risk during the surgical procedure, necessitating immediate intervention to prevent potential allergic reactions and ensure patient safety.
A: The client is able to mark the correct site for the surgery. This indicates understanding and participation in the surgical process, which is a positive sign rather than a concern.
B: The client can only tell the nurse about the surgery in lay terms. While medical terminology is preferred, the ability to communicate in simpler terms does not indicate a lack of understanding or awareness.
D: The client has signed a consent form for surgery and anesthesia. Signing the consent form demonstrates that the client has been informed and agrees to the procedure, indicating readiness rather than a need for intervention.
Which collaborative health-care team member should the nurse refer the client to in the late stages of myasthenia gravis?
Rationale:
D: Speech therapist. In the late stages of myasthenia gravis, clients may experience difficulties with communication and swallowing. A speech therapist specializes in addressing these issues, providing essential support to enhance the client’s quality of life.
A: Occupational therapist. While occupational therapists assist with daily living activities, they do not specifically target the communication and swallowing difficulties prevalent in late-stage myasthenia gravis.
B: Recreational therapist. Recreational therapists focus on leisure activities and therapeutic recreation, which do not address the critical communication and swallowing challenges faced by clients in advanced myasthenia gravis.
C: Vocational therapist. Vocational therapists primarily aid individuals in job-related skills and employment opportunities, lacking the specialization needed to manage the communication impairments associated with late-stage myasthenia gravis.
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?
Rationale:
Genetics may play a role in susceptibility to MS, but the disease may be caused by a virus. This statement reflects current understanding that multiple factors, including environmental influences, contribute to the development of multiple sclerosis, making it a complex condition rather than purely genetic.
B: There is no evidence suggesting there is any chromosomal involvement in developing MS. This oversimplifies the genetic aspect, as some studies indicate potential genetic predispositions linked to multiple sclerosis.
C: Multiple sclerosis is caused by a recessive gene, so both parents had to have the gene for the client to get MS. This statement misrepresents the inheritance pattern of MS, which is not solely determined by a single recessive gene.
D: Multiple sclerosis is caused by an autosomal dominant gene on the Y chromosome, so only fathers can pass it on. This is inaccurate since MS is not linked to a specific chromosomal pattern or exclusively inherited from one parent.