A nurse is providing fire safety training to a newly licensed nurse. Which of the following statements indicates an understanding of the teaching?

Rationale

• Encourage rigorous physical exercise to enhance mobility: While exercise can improve function, rigorous or high-intensity activity may exacerbate fatigue or trigger worsening of symptoms in MS. Exercise should be tailored to the client’s tolerance and done under professional guidance rather than encouraged rigorously at home. Overexertion may increase relapse risk or cause injury.

• Instruct the client to remove throw rugs from their home: Removing throw rugs reduces the risk of falls in clients with multiple sclerosis, especially those who have had gait disturbances or lower extremity weakness. Fall prevention is a standard safety intervention in MS care. This addresses environmental hazards and promotes safe ambulation at home.

• Request a provider referral for physical therapy: Physical therapy supports mobility, balance, and strength in clients with MS. PT interventions can help manage spasticity and prevent functional decline. Referral is appropriate for clients who continue to experience daily muscle spasms and intermittent functional limitations.

• Teach the client about self-administering glatiramer acetate: Glatiramer acetate is a disease-modifying therapy for MS, and teaching self-administration promotes adherence, autonomy, and consistent treatment. Education regarding proper technique, injection site rotation, and monitoring for side effects is a standard nursing intervention in MS management.

• Encourage the use of a hot tub to decrease muscle spasms: Hot tubs can exacerbate heat sensitivity in MS, potentially worsening muscle weakness, fatigue, or neurological symptoms. Heat intolerance is common in MS, making hot tub use an inappropriate intervention without professional guidance. Safer spasticity management strategies include stretching, PT, or pharmacologic interventions.

A. Orientation: The client is alert only to name and not fully oriented, indicating acute neurological changes. This requires immediate follow-up to assess for possible stroke or other neurological compromise.

B. Breath sounds: Breath sounds are vesicular and bronchovesicular with full thoracic excursion, which is within normal limits. No follow-up is immediately required.

C. Gag reflex: The absence of a gag reflex is a significant finding, increasing the risk of aspiration and airway compromise. Immediate assessment and interventions are necessary to protect the airway.

D. Pupils: Pupils are equal and reactive bilaterally, which is within normal limits. No follow-up is required for this finding.

E. Extremity circulation: Pulses are +2 with capillary refill less than 2 seconds in all extremities, indicating adequate perfusion. No follow-up is needed at this time.

F. Speech: The client’s speech is unintelligible, indicating acute neurological compromise. This requires urgent follow-up and possible intervention for stroke or transient ischemic attack.

G. Grip strength: Decreased grip strength in the right upper extremity indicates motor deficits consistent with neurological injury, requiring immediate assessment and intervention.

H. Thoracic findings: Full and symmetric thoracic excursion with normal breath sounds is within normal limits, requiring no follow-up.

I. Heart sounds: S1 and S2 are present, and the cardiac monitor shows sinus tachycardia without additional abnormalities, which does not require immediate follow-up.