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 A

Explanation

Choice A rationale:

Improved short-term memory. Donepezil is a medication used to treat Alzheimer's disease and other forms of dementia. It works by increasing the levels of certain chemicals in the brain that are involved in memory, thinking, and reasoning. Therefore, improved short-term memory is an indication that the medication is effective, as it suggests enhanced cognitive function in the client.

Choice B rationale:

Enhanced mood. While improved mood can be a positive outcome of treating dementia, it is not the primary goal of donepezil therapy. The main focus is on cognitive improvement, particularly in memory and thinking skills. Enhanced mood alone may not be a reliable indicator of the medication's effectiveness in this context.

Choice C rationale:

Can perform ADLs independently. The ability to perform activities of daily living (ADLs) independently is an important aspect of a patient's overall well-being. However, this improvement may not solely be attributed to the effects of donepezil. Other factors, such as rehabilitation or support services, can also contribute to the patient's ability to perform ADLs. While it is a positive outcome, it is not a specific indication of donepezil's effectiveness.

Choice D rationale:

Increased food intake. Increased food intake is not a direct effect of donepezil. Donepezil does not have a primary role in regulating appetite or food intake. Therefore, this finding is not a reliable indicator of the medication's effectiveness in treating dementia.

A. Tie a tourniquet around the leg distal to the wound. B. Irrigate the wound with sterile water. C. Apply direct pressure to the wound with thick dressing material. D. Apply a transparent dressing to the wound.

Correct Answer is C

Explanation

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Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is providing care for a client who has been receiving donepezil.Which of the following findings indicates that the medication is effective?

Correct Answer is A

Explanation

A nurse in an emergency department is caring for a client who is actively bleeding from a stab wound to the thigh.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A charge nurse is concerned about a recent increase in facility-acquired catheter infections.Which of the following actions should the nurse take first?

A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine.Which of the following findings should the nurse identify as a contraindication to the administration of clozapine?

A nurse is assessing a client who has type 1 diabetes mellitus and was administered insulin lispro 1 hr ago.Which of the following manifestations indicates that the client might be experiencing hypoglycemia?

A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client's coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of elder abuse?

A nurse is planning to delegate the fasting blood glucose testing for a client who has diabetes mellitus to an assistive personnel (AP). Which of the following actions should the nurse take?

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 providing discharge teaching to a client following a total gastrectomy.The nurse should instruct the client about which of the following medications?

A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion.Which of the following actions should the nurse include in the plan?