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.

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Correct Answer is D

Explanation

The correct answer is D. Urinary retention. Morphine is an opioid analgesic that can cause urinary retention by inhibiting bladder contractions and increasing sphincter tone. Urinary retention can lead to urinary tract infections, bladder distension, and renal impairment if not treated.

A. "You should take 600 milligrams of ibuprofen every 8 hours for discomfort during an outbreak." B. "You will need to have a cesarean birth if there are any visible lesions." C. "Your baby's cord blood will be tested to determine if she has contracted HSV." D. "You can apply a cortisone cream to the lesions twice each day." .

Correct Answer is B

Explanation

Choice A rationale:

Taking ibuprofen during pregnancy is generally not recommended, especially in high doses or for an extended period, as it can increase the risk of complications, including heart defects in the baby. Therefore, advising the client to take 600 milligrams of ibuprofen every 8 hours is not appropriate and potentially harmful during pregnancy.

Choice B rationale:

Having a cesarean birth (C-section) is recommended if there are visible lesions of genital herpes during labor and delivery. This precautionary measure helps prevent the transmission of the herpes simplex virus (HSV) from the mother to the baby, reducing the risk of neonatal herpes infection, which can be severe or even life-threatening.

Choice C rationale:

Testing the baby's cord blood for HSV is not a standard practice. Instead, if there are visible lesions or symptoms of herpes during labor, a C-section is often performed to minimize the risk of transmission. Testing the baby after birth may be done if there are concerns about potential exposure.

Choice D rationale:

Applying a cortisone cream to the lesions is not recommended without medical supervision during pregnancy. Topical corticosteroids, such as cortisone creams, can be absorbed through the skin and may have adverse effects on both the mother and the baby. It is essential to consult a healthcare provider before using any medications or creams during pregnancy to ensure safety for both the mother and the baby.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving morphine for pain. Which of the following findings indicates that the client is experiencing an adverse effect of the medication?

Correct Answer is D

Explanation

A nurse is teaching a client who is pregnant and has genital herpes simplex virus (HSV). Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse in a prenatal clinic is teaching a client about nonpharmacological pain management during labor. Which of the following statements by the client indicates an understanding of the teaching?

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A nurse is reinforcing teaching with a group of adolescents about safety.Which of the following information should the nurse include in the teaching?

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A nurse is developing a nutritional care plan for a client who has COPD and severe dyspnea. To promote intake, which of the following actions should the nurse include in the plan of care?

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