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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Increasing carbohydrate intake may prevent hypoglycemia but does not address the root cause, such as excessive insulin or oral hypoglycemic agents. Reviewing medications identifies dosing issues, ensuring safer management of type 2 diabetes, making it the priority over dietary changes.

Choice B reason: Reviewing the medication regimen is critical, as hypoglycemia in type 2 diabetes often results from excessive insulin or sulfonylureas. Adjusting doses or timing with a provider prevents recurrent episodes, addressing the primary cause and ensuring safe glycemic control, making it the priority action.

Choice C reason: Monitoring blood glucose hourly is reactive and impractical long-term. It confirms hypoglycemia but does not prevent it. Reviewing medications addresses the cause, such as inappropriate dosing, making it more effective for managing recurrent hypoglycemia in type 2 diabetes.

Choice D reason: High-protein snacks stabilize blood glucose but are secondary to addressing medication-related hypoglycemia. Excessive insulin or oral agents are likely causes, so reviewing the regimen is prioritized to correct dosing, preventing recurrent episodes more effectively than dietary adjustments alone.

A. Increased urine output B. Elevated blood pressure C. Increased heart rate D. Weight gain

Correct Answer is A

Explanation

Choice A reason: Furosemide, a loop diuretic, promotes urine output by inhibiting sodium reabsorption in the kidneys, reducing fluid overload in heart failure. Increased urine output indicates effective diuresis, alleviating pulmonary and peripheral edema, making it the primary sign of therapeutic efficacy.

Choice B reason: Elevated blood pressure is not an expected effect of furosemide, which reduces preload and blood volume, often lowering pressure. Effective diuresis is shown by increased urine output, as this directly reflects fluid removal, critical for heart failure management.

Choice C reason: Increased heart rate is not a direct indicator of furosemide efficacy. Diuresis reduces cardiac workload, potentially stabilizing heart rate, but urine output is the primary measure, as it confirms fluid excretion, the medication’s main action in heart failure.

Choice D reason: Weight gain indicates fluid retention, the opposite of furosemide’s goal. Effective diuresis causes weight loss due to fluid excretion. Increased urine output is the key sign, as it directly measures the diuretic’s action in reducing heart failure-related fluid overload.

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The nurse is caring for a client with a history of multiple sclerosis. Which intervention should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with type 2 diabetes mellitus who reports frequent episodes of hypoglycemia. Which action should the nurse prioritize?

Correct Answer is B

Explanation

A client with a history of heart failure is prescribed furosemide. Which assessment finding indicates the medication is effective?

Correct Answer is A

Explanation

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