A patient with a history of celiac disease has recently been diagnosed with multiple sclerosis.
The nurse is preparing to discharge the patient.
What is the most important instruction for the nurse to include in the discharge teaching plan?

Take prescribed cortisone accurately.

Use a walker when weakness occurs.

Increase daily intake of sodium in diet.

Avoid extreme environmental temperatures.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Taking prescribed cortisone accurately is crucial for managing multiple sclerosis symptoms. Cortisone is a type of steroid that can reduce inflammation and suppress the immune system, helping to manage MS symptoms.

Choice B rationale

Using a walker when weakness occurs can be beneficial for patients with multiple sclerosis as it can help them maintain mobility and independence. However, it is not the most important instruction for the nurse to include in the discharge teaching plan.

Choice C rationale

Increasing daily intake of sodium in the diet is not recommended for patients with multiple sclerosis. High sodium intake can exacerbate symptoms of multiple sclerosis and may increase the risk of relapses.

Choice D rationale

Avoiding extreme environmental temperatures can be beneficial for patients with multiple sclerosis as heat can worsen symptoms. However, it is not the most important instruction for the nurse to include in the discharge teaching plan.

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Correct Answer is C

Explanation

Choice A rationale

Auscultating an area six inches below the umbilicus would not provide the most useful data when assessing for possible urinary retention. Auscultation is typically used to assess bowel sounds and not typically used in the assessment of urinary retention.

Choice B rationale

Observing the appearance of the patient’s urine can provide some information about the patient’s hydration status and kidney function, but it would not be the most useful technique for assessing urinary retention.

Choice C rationale

Palpating the area above the pubic symphysis can provide useful data when assessing for possible urinary retention. If the bladder is distended due to urinary retention, it may be palpable in this area.

Choice D rationale

Measuring the girth of the patient’s lower abdomen is not typically used as a method to assess for urinary retention. While an increase in abdominal girth can occur with urinary retention, it is not the most direct or reliable method for assessment.

A. Thick, dry, and dark area on bilateral heels. B. Broken skin without evidence of undermining. C. Defined area of persistent redness over bone. D. Superficial sacral pressure injury with defined margins.

Correct Answer is C

Explanation

Choice A rationale

A thick, dry, and dark area on the heels could indicate a more advanced stage of a pressure injury, not the earliest indication.

Choice B rationale

Broken skin without evidence of undermining could also indicate a more advanced stage of a pressure injury.

Choice C rationale

A defined area of persistent redness over a bony prominence is often the earliest sign of a developing pressure injury. This is because these areas are more susceptible to pressure and have less padding to protect them.

Choice D rationale

A superficial sacral pressure injury with defined margins is a more advanced stage of a pressure injury.

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A patient with a history of celiac disease has recently been diagnosed with multiple sclerosis.The nurse is preparing to discharge the patient.What is the most important instruction for the nurse to include in the discharge teaching plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment technique would provide the most useful data when the nurse is concerned about possible urinary retention?

Correct Answer is C

Explanation

A client admitted with pneumonia and on bedrest has not had the strength to perform self-care.Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?

Correct Answer is C

Explanation

A parent brings a 4-month-old infant to the clinic.The infant has had a runny nose, a slight fever, and a cough for the last two days.Which of the following findings should alert the nurse that the child is in acute respiratory distress?

A 33-year-old female client, who denies smoking, drinking, or using any illicit drugs, exercises 2 to 3 times per week and has an office job.She weighs 68 kg and is 156 cm tall.Which of the following actions would be effective in maintaining her energy balance?

A patient with septic shock develops Disseminated Intravascular Coagulation (DIC). Which pathophysiological process should the nurse identify as the cause of the coagulation problem?

A straight catheter produced 500 mL of clear yellow urine. For each finding, indicate whether the findings suggest that the client’s condition has improved or put the client at risk for hypovolemia. Each column must have at least one selection.

The nurse has reviewed the patient’s chart.The nurse recognizes that this patient is hemorrhaging due to which condition?

A healthcare provider prescribes a low-fiber diet for a patient with ulcerative colitis.Which food selection by the patient indicates to the nurse that the patient understands the prescribed diet?

While changing a postoperative patient’s dressing, the nurse notices purulent drainage at the site.Before reporting this to the healthcare provider, which of the patient’s lab values should the nurse check?

A patient with a history of celiac disease has recently been diagnosed with multiple sclerosis.
The nurse is preparing to discharge the patient.
What is the most important instruction for the nurse to include in the discharge teaching plan?