A home care nurse is caring for a client who has advanced multiple.

sclerosis.

Nurses' Notes.

2 weeks ago:Today: The client reports depression is increasing as they are unable to. participate in activities they once enjoyed because of the.

advancing multiple sclerosis.

Even getting up to the wheelchair.

is "just too much" for them.

The home health aide reported client will not permit turning. position changes.

The client states, "I can only get comfortable.

curled on my left side.

I'm not moving.". Vital Signs.

Today:Temperature 36.8° C (98.2° F). Heart rate 80/min.

Respiratory rate 20/min.

BP 116/76 mm Hg. Client Education.

1 week ago:Educated the client about the importance of getting out of bed.

changing positions in bed.

Client stated, ""l try.". Select the 5 complications the client is at risk for.

Contractures.

Calcium resorption.

Hypocalcemia.

Diarrhea.

Urinary stasis.

Answer and Explanation

Correct Answer : A,E

Choice A rationale:
Contractures are a risk for this client due to the lack of movement and constant positioning on one side. Contractures occur when the muscles, tendons, or ligaments shorten and tighten, limiting range of motion and flexibility. This can be a result of prolonged immobility or lack of use of the muscles.
Choice B rationale:
Calcium resorption is not a risk for this client. Calcium resorption refers to the process where bone tissue is broken down and calcium is released into the bloodstream. This process is not directly related to immobility or multiple sclerosis.
Choice C rationale:
Hypocalcemia, or low calcium levels in the blood, is also not a direct risk for this client. While immobility can lead to bone loss over time, it does not directly cause hypocalcemia.
Choice D rationale:
Diarrhea is not a risk for this client based on the information provided. Diarrhea can be a symptom of many conditions but there is no indication in the scenario that this client is at risk.
Choice E rationale:
Urinary stasis is a risk for this client due to their immobility. When a person is immobile, urine can pool in the bladder, creating an environment where bacteria can grow, potentially leading to urinary tract infections.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale:

Using a 12-point font when printing written materials is helpful for readability, especially for individuals with visual impairments. However, this action alone does not necessarily promote meaningful learning. The content and presentation style are equally important.

Choice B rationale:

Presenting information using abstract concepts can be confusing, especially for older adults. Using concrete examples and simple language facilitates better understanding. Abstract concepts are more challenging to grasp, especially for individuals who might be experiencing cognitive decline.

Choice C rationale:

Connecting new information with the client's past experiences enhances learning and retention. Relating new knowledge to familiar situations or memories helps create cognitive associations, making it easier for the client to understand and remember the information. This technique is particularly effective in promoting learning among older adults.

Choice D rationale:

Speaking loudly when addressing the client is unnecessary and can be perceived as rude or patronizing. Clear and audible speech is essential, but shouting or raising the volume excessively is not respectful and does not enhance the learning experience.

A. Keep calcium gluconate at the client's bedside. B. Attach an inline filter to the IV tubing. C. Protect the IV bag from exposure to light. D. Monitor blood pressure every 2 hr.

Correct Answer is C

Explanation

Answer is: c. Protect the IV bag from exposure to light.

Explanation: Nitroprusside degrades when exposed to light, so the nurse should protect the IV bag from light exposure to maintain the medication's potency and effectiveness in treating the client's severe hypertension.

Choice a. is wrong because calcium gluconate is used as an antidote for magnesium sulfate toxicity. Although it may be kept on hand in some facilities, it is not directly related to the administration of nitroprusside.

Choice b. is wrong because attaching an inline filter is not necessary when administering nitroprusside. It is more relevant for medications that require filtration, such as certain chemotherapeutic agents.

Choice d. is wrong because monitoring blood pressure every 2 hours is not frequent enough for a client receiving nitroprusside. The nurse should monitor the client's blood pressure more frequently, such as every 5 to 15 minutes, depending on facility policies and the client's condition.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing preoperative teaching to an older adult client who is scheduled for surgery.Which of the following actions should the nurse take to promote learning?

Correct Answer is C

Explanation

A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse is caring for a client who is postoperative following total hip arthroplasty.Which of the following actions should the nurse take to prevent dislocation of the prosthesis?

A nurse is caring for a client who has a recent diagnosis of a terminal illness. The nurse should identify which of the following as an indication of hopelessness?

A nurse is caring for a client who is alert and oriented and is receiving continuous ECG monitoring.The cardiac rhythm strip shows a wavy baseline, no distinguishable P waves, and an increased heart rate.The nurse should identify the cardiac rhythm as which of the following?

A nurse is planning care for a client who is to receive alteplase recombinant for a thrombus in the coronary artery. Which of the following actions should the nurse include in the plan of care?

A home care nurse is making a follow-up visit with a client who has COPD and is using a compressed oxygen system in his home.Which of the following actions should the nurse take?

A nurse is preparing a client for transfer to a long-term rehabilitation facility following a below-the-knee amputation of the right leg.Which of the following actions should the nurse take to protect the client's confidentiality?

A nurse is caring for a child who has terminal cancer. Which of the following responses by the child's school-age brother should the nurse expect?

A nurse is caring for a client who is pregnant. Exhibits The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.