A nurse is providing teaching to a client who has a new diagnosis of multiple sclerosis. Which of the following statements should the nurse make?
"Use a cane when walking to maintain your balance."
"Plan to take a hot bath once a week to reduce stress."
"Engage in a rigorous exercise program to maintain muscle tone."
"Place a scatter rug in your bathroom to prevent falling"
The Correct Answer is A
Choice A reason:
"Use a cane when walking to maintain your balance" is the correct statement Multiple sclerosis (MS) is a chronic autoimmune condition that affects the central nervous system, leading to various neurological symptoms. Mobility and balance issues are common among individuals with MS, and using a cane can be helpful in providing stability and support while walking. It can also reduce the risk of falls and improve the client's overall safety and confidence when ambulating.
Choice B reason:
"Plan to take a hot bath once a week to reduce stress” is not appropriate statement. Heat sensitivity is a common symptom in individuals with MS, and exposure to heat, such as hot baths or saunas, can exacerbate MS symptoms. It is generally advisable for individuals with MS to avoid excessive heat exposure as it can worsen fatigue and other neurological symptoms.
Choice C reason:
"Engage in a rigorous exercise program to maintain muscle tone" is not appropriate. While exercise is beneficial for individuals with MS, particularly in maintaining muscle strength and flexibility, it is essential to avoid a rigorous or overly strenuous exercise program. High-intensity exercise may lead to increased fatigue and exacerbation of MS symptoms. A personalized exercise plan that considers the individual's specific abilities and limitations is recommended.
Choice D reason
"Place a scatter rug in your bathroom to prevent falling" is not appropriate statement. Placing a scatter rug in the bathroom is not advisable, especially for individuals with mobility and balance issues like those with MS. Scatter rugs can create tripping hazards and increase the risk of falls. It is essential to keep the bathroom floor clear and use non-slip mats to improve safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Incorrect. Decreased blood pressure is not an indication of chlorpromazine effectiveness, but rather a potential adverse effect that should be monitored and reported.
B: Correct. Decreased hallucinations are an indication of chlorpromazine effectiveness, as this medication is an antipsychotic that blocks dopamine receptors in the brain and reduces psychotic symptoms such as hallucinations, delusions, and paranoia.
C: Incorrect. Decreased cholesterol is not an indication of chlorpromazine effectiveness, but rather a potential benefit that may occur due to its effect on lipid metabolism.
D: Incorrect. Decreased esophageal reflux is not an indication of chlorpromazine effectiveness, but rather a potential adverse effect that should be avoided by taking the medication with food or water and avoiding lying down after administration.
Correct Answer is ["A","B","C"]
Explanation
A. Assess peripheral circulation hourly. This is correct because clients with SCD are at risk of vaso-occlusive crisis, which can impair blood flow to the extremities and cause tissue ischemia and necrosis. The nurse should monitor for signs of poor circulation such as pallor, coolness, numbness, or pain.
B. Assess the client's mouth every 8 hr. This is correct because clients with SCD are prone to oral ulcers, infections, and dental problems due to chronic anemia and reduced oxygen delivery to the oral mucosa. The nurse should inspect the mouth for lesions, bleeding, inflammation, or infection and provide oral hygiene as needed.
C. Use humidification with oxygen therapy. Administer IV fluids. This is correct because clients with SCD need adequate hydration and oxygenation to prevent sickling of red blood cells and further complications. Humidification helps moisten the airways and prevent dehydration of the mucous membranes. IV fluids help maintain fluid and electrolyte balance and reduce blood viscosity.
D. Raise the knee position on the client's bed. This is incorrect because this can impede venous return and worsen peripheral circulation. The nurse should keep the client's extremities in a neutral position and avoid tight or restrictive clothing or devices.
E. Use an automated blood pressure cuff on the client's arm. Prepare for platelet transfusion. This is incorrect because this can cause mechanical trauma to the arm and trigger a vaso-occlusive crisis. The nurse should use a manual blood pressure cuff and avoid applying pressure to the arm. Platelet transfusion is not indicated for clients with SCD unless they have thrombocytopenia or bleeding.
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