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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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Encourage the client to include celery in their diet: Celery is high in fiber and stringy, which can increase the risk of obstruction in a client with a new ileostomy. Clients should avoid foods that can block the stoma until healing is complete and they are accustomed to managing their ostomy.

B. Cleanse around the client's stoma with hydrogen peroxide: Hydrogen peroxide can damage healthy skin and tissue around the stoma. The area should be cleansed gently with warm water and mild soap, avoiding harsh or irritating substances to promote skin integrity.

C. Cut the skin barrier opening 2.5 cm (1 in) larger than the stoma: The skin barrier opening should be no more than 1/8 inch (about 0.3 cm) larger than the stoma. A larger opening exposes more skin to stoma output, increasing the risk for skin irritation and breakdown.

D. Empty the client's pouch when it is halfway full: Emptying the pouch when it is about halfway full prevents the weight from pulling on the seal, reducing the risk of leaks and protecting the skin. It also maintains client comfort and reduces the chance of pouch rupture.

A. Fats B. Calcium C. Vitamin D D. Protein

Correct Answer is D

Explanation

A. Fats: While fats provide energy and help with cell membrane structure, they are not the primary nutrient required to promote wound healing. Excess fat intake without proper balance may not directly aid in faster tissue repair.

B. Calcium: Calcium is important for bone health and muscle function but does not play a central role in soft tissue wound healing. It is more critical in fracture healing rather than open wound repair.

C. Vitamin D: Vitamin D supports calcium absorption and bone health. Although it contributes to immune function, it is not the main nutrient needed to directly repair skin and soft tissue wounds.

D. Protein: Protein is essential for wound healing because it supports cell growth, tissue repair, and immune function. Adequate protein intake is critical to form new tissue, promote collagen synthesis, and restore skin integrity in clients with open wounds.

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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

A nurse is contributing to the plan of care for a client who has a new ileostomy. Which of the following actions should the nurse include?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who has an open leg wound and is experiencing difficulty healing. The nurse should encourage the client to increase which of the following nutrients in his diet?

Correct Answer is D

Explanation

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