The nurse is caring for a client with multiple sclerosis. What action does the nurse implement to increase venous return, prevent stiffness, and maintain muscle strength and endurance?
Administer corticosteroids
Turn and reposition every 2 hours
Administer interferon
Encourage range-of-motion exercises
The Correct Answer is D
Choice A: Administer corticosteroids. This is incorrect because corticosteroids are used to reduce inflammation and suppress the immune system, but they do not directly affect venous return, stiffness, or muscle strength and endurance.
Choice B: Turn and reposition every 2 hours. This is incorrect because turning and repositioning are important to prevent pressure ulcers and promote circulation, but they are not sufficient to maintain muscle strength and endurance. The client also needs active or passive exercises to prevent muscle atrophy and contractures.
Choice C: Administer interferon. This is incorrect because interferon is a type of immunomodulator that can reduce the frequency and severity of relapses in multiple sclerosis, but it does not directly affect venous return, stiffness, or muscle strength and endurance.
Choice D: Encourage range-of-motion exercises. This is correct because range-of-motion exercises can help increase venous return, prevent stiffness, and maintain muscle strength and endurance in clients with multiple sclerosis. Range-of-motion exercises can be performed actively by the client or passively by the nurse or a caregiver. They should be done at least twice a day to prevent complications such as contractures, spasticity, and pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Hypertension is a manifestation of increased intracranial pressure, as it reflects the body's attempt to maintain adequate cerebral perfusion pressure (CPP) and blood flow to the brain. CPP is the difference between the mean arterial pressure (MAP) and the intracranial pressure (ICP). When ICP rises, MAP must also rise to keep CPP constant and prevent cerebral ischemia. Hypertension is part of the Cushing's triad, which is a classic sign of increased ICP that also includes bradycardia and irregular respirations.
Choice B reason: Tinnitus is not a manifestation of increased intracranial pressure, as it does not affect the auditory system. Tinnitus is a ringing, buzzing, or hissing sound in the ears that can be caused by various factors, such as ear infections, noise exposure, medications, or aging. Tinnitus may be associated with other neurological conditions, such as Meniere's disease, acoustic neuroma, or multiple sclerosis, but not with increased ICP.
Choice C reason: Hypotension is not a manifestation of increased intracranial pressure, as it indicates a decrease in MAP and CPP, which can lead to cerebral ischemia and infarction. Hypotension can be caused by various factors, such as blood loss, dehydration, shock, or medications. Hypotension may worsen the outcome of increased ICP by reducing the oxygen and nutrient delivery to the brain.
Choice D reason: Tachycardia is not a manifestation of increased intracranial pressure, as it contradicts Cushing's triad. Tachycardia is an increase in heart rate that can be caused by various factors, such as anxiety, pain, fever, dehydration, or medications. Tachycardia may increase the oxygen demand and metabolic rate of the brain, which can exacerbate the effects of increased ICP.
Correct Answer is A
Explanation
Choice A reason: Planning medication doses to occur before meals is a good suggestion to improve the client's nutritional status. Myasthenia gravis is a neuromuscular disorder that causes weakness and fatigue of the voluntary muscles, especially those involved in chewing and swallowing. Taking anticholinesterase medications before meals can enhance muscle strength and coordination, and make it easier for the client to eat and avoid choking or aspiration.
Choice B reason: Restricting drinking fluids before and during meals is not a good suggestion to improve the client's nutritional status. Fluid intake is important for hydration and digestion, and should not be limited unless there is a medical reason, such as fluid overload or heart failure. Drinking fluids before and during meals can also help lubricate the food and prevent dryness or irritation of the mouth and throat.
Choice C reason: Increasing the amount of fat and carbohydrates in meals is not a good suggestion to improve the client's nutritional status. Fat and carbohydrates are sources of energy, but they can also increase the risk of obesity, diabetes, or cardiovascular disease if consumed excessively. A balanced diet that includes adequate protein, vitamins, minerals, and fiber is more beneficial for the client's health and well-being.
Choice D reason: Eating three large meals per day is not a good suggestion to improve the client's nutritional status. Eating large meals can be difficult and exhausting for the client with myasthenia gravis, as their muscle strength and endurance may decline over time. Eating smaller and more frequent meals can help maintain the energy level and prevent fatigue or hunger.
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