The nurse is caring for a client with multiple sclerosis. What actions 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 reason: Administering corticosteroids is not an action that the nurse implements to increase venous return, prevent stiffness, and maintain muscle strength and endurance because it is a medication that reduces inflammation and relieves acute exacerbations of multiple sclerosis, but does not affect the client's physical function or mobility.
Choice B reason: Turning and repositioning every 2 hours is not an action that the nurse implements to increase venous return, prevent stiffness, and maintain muscle strength and endurance because it is a nursing intervention that prevents pressure ulcers and promotes skin integrity, but does not enhance the client's circulation or muscle activity.
Choice C reason: Administering interferon is not an action that the nurse implements to increase venous return, prevent stiffness, and maintain muscle strength and endurance because it is a medication that modifies the immune system and delays the progression of multiple sclerosis, but does not improve the client's physical function or mobility.
Choice D reason: Encouraging range-of-motion exercises is an action that the nurse implements to increase venous return, prevent stiffness, and maintain muscle strength and endurance because it is a physical activity that improves the client's blood flow, flexibility, and muscle tone, as well as prevents contractures and spasticity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A reason: Nurses performing duties outside of the nurses' typical job description is not a component of a disaster plan. Nurses should only perform tasks that are within their scope of practice, license, and competencE.
Choice B reason: A plan for comprehensive practice drills is a component of a disaster plan. Nurses should be involved in conducting regular drills to test and improve the preparedness and response of the staff and facility.
Choice C reason: Identification of resources to meet anticipated needs for food, water, and supplies is a component of a disaster plan. Nurses should be involved in assessing and securing the necessary resources to provide adequate care and support for the clients and staff during a disaster.
Choice D reason: An internal and external communication plan is a component of a disaster plan. Nurses should be involved in establishing and maintaining effective communication channels with other health care providers, agencies, authorities, media, and community during a disaster.
Choice E reason: Discharge all surgical clients who are one day or more post-op is not a component of a disaster plan. Nurses should not discharge clients without proper assessment, documentation, education, and follow-up arrangements.
Correct Answer is C
Explanation
Choice A reason: Gradual onset of several hours is not a manifestation of a hemorrhagic strokE. Hemorrhagic strokes occur when a blood vessel bursts in or near the brain, causing rapid bleeding and increased intracranial pressurE.
Choice B reason: Maintains consciousness is not a manifestation of a hemorrhagic strokE. Hemorrhagic strokes often cause loss of consciousness due to compression or damage of brain tissuE.
Choice C reason: Sudden severe headache is a manifestation of a hemorrhagic strokE. Hemorrhagic strokes can cause intense pain in the head due to bleeding and pressure on nerve endings.
Choice D reason: History of neurologic deficits lasting less than 1 hour is not a manifestation of a hemorrhagic strokE. Neurologic deficits lasting less than 1 hour are more indicative of a transient ischemic attack (TIA), which is caused by temporary blockage or narrowing of blood vessels in or leading to the brain.
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