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: It is a tool that is used to determine your maximum level of self-sufficiency as the appropriate nursing response, as it accurately describes the purpose and function of the FIM. The FIM measures how much assistance you need to perform 18 activities of daily living, such as eating, dressing, toileting, walking, and communicating. The FIM helps to evaluate your functional status, monitor your progress, and plan your rehabilitation goals and interventions. ¹²³
Choice B reason: It is a test that determines which activities you feel most comfortable performing is not an appropriate nursing response, as it does not reflect the objective and standardized nature of the FIM. The FIM is not a subjective or self-reported measure of your preferences or comfort level, but rather an observational and rating scale that assesses your actual performance and independence in various tasks. The FIM uses a 7-point ordinal scale that ranges from 1 (total assistance) to 7 (complete independence) and requires trained and certified raters to administer and score it. ¹²³
Choice C reason: It is a tool used by insurance companies to determine qualifications for medical reimbursement is not an appropriate nursing response, as it does not capture the primary purpose and benefit of the FIM. The FIM is not a financial or administrative tool that determines your eligibility or coverage for medical services, but rather a clinical and research tool that measures your functional outcomes and quality of care. The FIM provides a uniform system of measurement for disability based on the International Classification of Impairment, Disabilities, and Handicaps and allows for comparison and evaluation of different rehabilitation programs and settings. ¹²³
Choice D reason: It is a tool that is used to assess what services you will need a home health aide to perform for you is not an appropriate nursing response, as it does not reflect the comprehensive and multidimensional scope of the FIM. The FIM is not a specific or limited tool that assesses only your home care needs or dependence on others, but rather a general and broad tool that assesses your functional abilities and disabilities in various domains and environments. The FIM covers both motor and cognitive aspects of functioning, such as comprehension, expression, social interaction, problem-solving, and memory. The FIM can be used with all diagnoses within rehabilitation and can be applied across different levels and settings of care.
Correct Answer is ["A","C","E"]
Explanation
Choice A reason: The integumentary system is a portal of entry for anthrax because the bacteria can enter through cuts or abrasions on the skin. This is called cutaneous anthrax, and it is the most common and least deadly form of anthrax infection.
Choice B reason: The endocrine system is not a portal of entry for anthrax because the bacteria do not affect the glands or hormones of the body. The endocrine system is mainly involved in regulating metabolism, growth, development, and reproduction.
Choice C reason: The central nervous system is a portal of entry for anthrax because the bacteria can spread to the brain and spinal cord from other parts of the body. This is called meningeal anthrax, and it is a rare and fatal complication of anthrax infection.
Choice D reason: The renal system is not a portal of entry for anthrax because the bacteria do not infect the kidneys or urinary tract. The renal system is mainly involved in filtering waste products and excess fluids from the blood.
Choice E reason: The respiratory system is a portal of entry for anthrax because the bacteria can be inhaled into the lungs. This is called inhalation anthrax, and it is the most deadly form of anthrax infection.
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