A nurse is assisting with planning care for a client who has a new diagnosis of multiple sclerosis. Which of the interventions should the nurse recommend?

Recommend frequent hot baths.

Encourage the client to restrict performing range-of-motion exercises.

Monitor the client's ability to perform ADLS.

Initiate contact precautions.

Answer and Explanation

The Correct Answer is C

A. Recommend frequent hot baths: Hot baths can exacerbate symptoms in clients with multiple sclerosis by increasing fatigue and worsening muscle weakness due to a rise in core body temperature. Clients are usually advised to avoid overheating and use cooling strategies instead to manage their symptoms.

B. Encourage the client to restrict performing range-of-motion exercises: Range-of-motion exercises are important in maintaining joint flexibility, muscle strength, and overall mobility. Restricting these exercises could lead to increased stiffness, weakness, and decreased functional ability in clients with multiple sclerosis.

C. Monitor the client's ability to perform ADLs: Monitoring the client's ability to perform activities of daily living is essential because multiple sclerosis often leads to progressive physical limitations. Regular assessment helps in planning appropriate interventions, promoting independence, and adjusting care as the disease progresses.

D. Initiate contact precautions: Contact precautions are not necessary for clients with multiple sclerosis because it is not an infectious disease. Multiple sclerosis is an autoimmune, neurodegenerative condition that requires supportive care rather than infection control measures.

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Correct Answer is B

Explanation

A. Clay-colored stools: Clay-colored stools indicate a lack of bile flow due to liver dysfunction, which is expected in cirrhosis. While concerning, it is not the most urgent finding compared to signs indicating acute neurological compromise.

B. Confusion: Confusion suggests hepatic encephalopathy, a serious complication of cirrhosis resulting from the buildup of toxins like ammonia in the bloodstream. It indicates potential cerebral impairment and requires immediate provider notification and intervention to prevent progression to coma.

C. Spider angiomas: Spider angiomas are small, dilated blood vessels visible on the skin, commonly seen in cirrhosis due to hormonal changes and altered vascular dynamics. They are a chronic sign of liver disease and do not represent an immediate threat.

D. Jaundice: Jaundice results from elevated bilirubin levels due to impaired liver function. While jaundice signals worsening liver disease, it develops gradually and is less immediately life-threatening than the onset of neurological symptoms like confusion.

A. Smoking in bed B. Leaving the stove on C. Lack of smoke detectors D. Placing a space heater 5ft from bed

Correct Answer is A

Explanation

A. Smoking in bed: Smoking in bed is a major fire hazard and one of the leading causes of residential fires. Falling asleep with a lit cigarette can easily ignite bedding, mattresses, or upholstered furniture, leading to fast-spreading, deadly fires. This behavior significantly increases the risk of injury or death from residential fires.

B. Leaving the stove on: Leaving the stove unattended can also cause kitchen fires, but cooking-related incidents typically lead to localized fires rather than being the top cause of overall residential fires. Proper supervision while cooking is important, but smoking in bed remains a more dangerous, widespread cause of fatal home fires.

C. Lack of smoke detectors: Lack of smoke detectors does not cause fires but delays detection, increasing the risk of injury or death once a fire has already started. While smoke detectors are crucial for early warning and safety, they are not an ignition source that directly leads to the start of residential fires.

D. Placing a space heater 5ft from bed: Placing a space heater 5 feet away from a bed is generally considered safe, as heaters need clearance but are unlikely to cause fires at that distance. Improper use of space heaters can be hazardous, but when correctly placed, they are not the primary cause of residential fires compared to smoking in bed.

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A nurse is assisting with planning care for a client who has a new diagnosis of multiple sclerosis. Which of the interventions should the nurse recommend?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is A

Explanation

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