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 A
Explanation
Choice A reason: Consistent salt intake is critical for lithium, as sodium levels affect lithium excretion. Low sodium increases lithium toxicity, causing tremors or confusion. Maintaining stable sodium intake ensures therapeutic levels, making this the priority teaching point for safe lithium therapy.
Choice B reason: Avoiding high-fiber foods is irrelevant to lithium therapy. Fiber affects gastrointestinal health but not lithium pharmacokinetics. Consistent salt intake is essential, as sodium fluctuations alter lithium clearance, risking toxicity, making dietary sodium the priority teaching focus.
Choice C reason: Increasing caffeine is inappropriate, as it may exacerbate bipolar symptoms and increase lithium excretion, risking subtherapeutic levels. Consistent salt intake stabilizes lithium levels, preventing toxicity or inefficacy, making it the critical teaching point for effective bipolar management.
Choice D reason: Limiting physical exercise is unnecessary for lithium therapy. Exercise supports mental health in bipolar disorder but does not directly affect lithium levels. Consistent salt intake is the priority, as sodium balance ensures safe and effective lithium therapy.
Correct Answer is B
Explanation
Choice A reason: Anorexia is common in hepatitis due to systemic inflammation but is nonspecific, occurring in many conditions. Clay-colored stools directly indicate impaired bile excretion from liver dysfunction, a hallmark of hepatitis, making it a more diagnostic finding.
Choice B reason: Clay-colored stools are highly indicative of hepatitis, as liver inflammation impairs bile production or excretion, reducing bilirubin in feces. This causes pale stools, reflecting hepatic dysfunction, making it a key finding to confirm hepatitis over nonspecific symptoms like anorexia.
Choice C reason: Brown, foamy urine is not typical of hepatitis. Dark urine from bilirubinuria may occur, but foamy urine suggests proteinuria, unrelated to liver dysfunction. Clay-colored stools are more specific, indicating bile flow obstruction, a direct sign of hepatitis pathology.
Choice D reason: Hematemesis indicates gastrointestinal bleeding, not a primary hepatitis feature. While advanced liver disease may cause variceal bleeding, clay-colored stools are an earlier, more specific sign of hepatitis-related bile impairment, making them the priority finding in acute cases.
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