The nurse is caring for a client with a history of multiple sclerosis. Which intervention should the nurse prioritize?
Assist with mobility and safety measures
Encourage high-sodium diet
Restrict physical therapy
Promote bed rest
The Correct Answer is A
Choice A reason: Assisting with mobility and safety is critical in multiple sclerosis, as muscle weakness and spasticity increase fall risk. Physical therapy and assistive devices enhance safety, reducing injury risk, making it the priority intervention to maintain independence and prevent complications like fractures.
Choice B reason: A high-sodium diet is inappropriate, as it may exacerbate fluid retention, unrelated to multiple sclerosis. Mobility assistance is the priority, as falls are a significant risk due to neurological deficits, making dietary sodium irrelevant to primary symptom management.
Choice C reason: Restricting physical therapy worsens mobility and spasticity in multiple sclerosis. Assisting with mobility and safety is critical, as it prevents falls and maintains function, making therapy restriction counterproductive, as exercise supports neurological health and independence.
Choice D reason: Promoting bed rest increases muscle atrophy and spasticity in multiple sclerosis. Mobility and safety measures are essential, as they reduce fall risk and maintain function, making bed rest detrimental to managing neurological symptoms and overall patient well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Open-angle glaucoma involves chronic optic nerve damage due to impaired aqueous humor drainage, not a reversible “angle” change. Medications reduce intraocular pressure but cannot restore anatomical angles. This response is inaccurate, as the condition requires lifelong management to prevent further nerve damage and vision loss.
Choice B reason: Open-angle glaucoma requires lifelong medication to maintain normal intraocular pressure, preventing optic nerve damage. Medications like prostaglandin analogs or beta-blockers enhance aqueous humor outflow or reduce production, controlling pressure long-term. This is the accurate response, as sustained pressure management is essential to preserve vision in chronic glaucoma.
Choice C reason: Reducing excess pressure is a goal of glaucoma treatment, but open-angle glaucoma is chronic, requiring ongoing medication even after pressure is lowered. This response is incomplete, as it suggests a temporary treatment, whereas lifelong therapy is needed to prevent pressure spikes and progressive optic nerve damage.
Choice D reason: Open-angle glaucoma is typically painless and not associated with swelling. Medications target intraocular pressure, not pain or inflammation. This response is inaccurate, as it misaligns with the pathophysiology of glaucoma, which involves optic nerve damage from pressure, not inflammatory or painful symptoms.
Correct Answer is A
Explanation
Choice A reason: Age over 40 increases cholelithiasis risk due to reduced gallbladder motility and increased bile cholesterol saturation, promoting gallstone formation. Aging alters bile composition, with higher lithogenic potential, making older adults more susceptible to cholesterol gallstones, a primary type in Western populations.
Choice B reason: Daily walking of 2 to 3 miles reduces cholelithiasis risk by promoting physical activity, which enhances gallbladder motility and reduces bile stasis. Exercise lowers cholesterol levels in bile, decreasing stone formation, making this a protective factor rather than a risk.
Choice C reason: A low-fat diet decreases cholelithiasis risk by reducing dietary cholesterol intake, which lowers bile cholesterol saturation. This promotes healthier bile composition, reducing the likelihood of cholesterol gallstone formation, making it a protective dietary habit rather than a risk factor.
Choice D reason: Male gender is associated with a lower risk of cholelithiasis compared to females, who have higher estrogen levels that increase bile cholesterol. Men have less lithogenic bile, making gender a protective factor, not a significant risk, unlike age-related changes.
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