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 D
Explanation
Choice A reason: Obtaining an arterial blood gas assesses oxygenation and acid-base status, useful in COPD management, but is not required before postural drainage. This invasive procedure is unnecessary for routine drainage, which mobilizes secretions. Explaining positions prepares the client, enhancing cooperation and effectiveness.
Choice B reason: Performing drainage after meals risks aspiration or vomiting, as a full stomach increases intra-abdominal pressure in COPD patients. Postural drainage is most effective when performed on an empty stomach, making this approach incorrect. Patient education on positioning is the priority.
Choice C reason: Shallow, fast breathing is counterproductive in COPD, as it reduces tidal volume and worsens hypercapnia. Postural drainage requires slow, deep breaths to mobilize secretions and improve ventilation. Explaining positions ensures proper technique, making this breathing instruction incorrect.
Choice D reason: Explaining that the client may be placed in five positions (e.g., prone, supine, lateral) prepares them for postural drainage, which uses gravity to mobilize lung secretions in COPD. This education enhances compliance and effectiveness, as proper positioning is critical for therapeutic success, making it the correct approach.
Correct Answer is A
Explanation
Choice A reason: Rinsing the mouth after using a corticosteroid inhaler prevents oral candidiasis, a common side effect from residual steroid deposition. This ensures safe asthma management, as fungal infections compromise adherence and health, making it the priority teaching point for proper inhaler use.
Choice B reason: Using the inhaler only during asthma attacks applies to rescue inhalers, not maintenance corticosteroids, which are used daily. This is incorrect, as rinsing the mouth is essential for corticosteroid inhalers to prevent oral thrush, ensuring safe and effective asthma control.
Choice C reason: Storing inhalers in a refrigerator is unnecessary and may degrade some medications. Room-temperature storage is standard. Rinsing the mouth after corticosteroid inhaler use is critical to prevent oral candidiasis, making it the priority teaching point for asthma management.
Choice D reason: Shaking the inhaler only once may be insufficient for proper aerosolization in some devices. Rinsing the mouth after corticosteroid inhaler use is the priority, as it prevents oral thrush, a significant side effect, ensuring safe and consistent asthma therapy.
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