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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale:

Administering 2 ounces of water to the newborn prior to the test is not a standard practice for newborn genetic screening. Newborns are typically screened for genetic disorders through a blood test, not by giving them water.

Choice B rationale:

This statement is incorrect. Newborn genetic screening is usually performed shortly after birth, not at 2 months old. Early screening allows for the early detection of certain genetic disorders, enabling timely interventions if needed.

Choice D rationale:

Drawing blood from the newborn's inner elbow is not specific guidance related to newborn genetic screening. Blood can be drawn from various sites, and healthcare providers choose the most appropriate site based on the newborn's condition and the required tests.

A. Crackles in lungs. B. Decreased thirst. C. Poor skin turgor. D. Tachycardia.

Correct Answer is A

Explanation

Choice A rationale:

Crackles in the lungs are a common manifestation of heart failure. Heart failure can cause fluid accumulation in the lungs, leading to crackles upon auscultation. This finding is due to pulmonary congestion and is indicative of heart failure exacerbation.

Choice B rationale:

Decreased thirst is not a typical manifestation of heart failure. In fact, patients with heart failure often experience increased thirst due to fluid shifts and increased blood volume, leading to increased urine output and dehydration.

Choice C rationale:

Poor skin turgor is not a specific manifestation of heart failure. Skin turgor is commonly assessed to determine hydration status, but it is not directly related to heart failure.

Choice D rationale:

Tachycardia (rapid heart rate) is a common manifestation of heart failure. The heart beats faster to compensate for its decreased pumping efficiency. Tachycardia helps maintain cardiac output, but it is not a primary cause of heart failure; instead, it is a physiological response to the condition.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to the parents of a newborn about newborn genetic screening.Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who has heart failure.Which of the following manifestations should the nurse expect?

Correct Answer is A

Explanation

A nurse is teaching a client about a variety of stress management techniques. Which of the following instructions by the nurse is appropriate?

A nurse is admitting a client who has rubella. Which of the following actions should the nurse plan to take?

A nurse is taking care of a client who is cognitively impaired. The nurse recognizes that which of the following rooms will provide a therapeutic environment for this client?

A charge nurse is monitoring a newly licensed nurse who is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following statements by the newly licensed nurse indicates an understanding of the procedure?

A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing.Which of the following examples should the nurse include in the teaching as an example of malpractice?

A nurse is assessing a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate 4 hr ago.The nurse notes pink-tinged urine in the drainage bag.Which of the following actions should the nurse take?

A nurse is caring for a client who has end-stage kidney disease.The client's adult child asks the nurse about becoming a living kidney donor for their parent.Which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure?

A nurse is collecting data from a client who is 18 hr postpartum. The nurse notes that the client is in the "taking-in phase of maternal adjustment. Which of the following manifestations should the nurse expect?