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

Answer and Explanation

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.

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Correct Answer is B

Explanation

In this scenario, the sudden regurgitation and cyanosis in a 24-hour-old infant indicate a potential airway obstruction or compromise. The immediate priority is to clear the airway and ensure adequate ventilation.

Suctioning the oral and nasal passages helps remove any potential obstruction or mucus that may be causing the cyanosis. This intervention aims to restore normal airﬂow and prevent further respiratory distress in the infant.

Let's brieﬂy evaluate the other options:

a) Turn the infant onto the right side.

Positioning the infant onto the right side does not directly address the potential airway obstruction or cyanosis. While positioning may have some benefit in certain situations, such as facilitating drainage, it is not the most appropriate immediate intervention in this case.

c) Give oxygen by positive pressure.

Administering oxygen by positive pressure may be necessary if the infant's oxygen saturation remains low after suctioning and clearing the airway. However, suctioning should be the initial intervention to address any potential airway obstruction or mucus before considering oxygen administration.

d) Stimulate the infant to cry.

Stimulating the infant to cry is not the appropriate intervention in this case. It does not directly address the potential airway obstruction or cyanosis. Crying requires a patent airway, and if the infant is already cyanotic, it suggests an obstruction or inadequate ventilation. Therefore, suctioning and clearing the airway take precedence over stimulating the infant to cry.

In summary, when a full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic, the practical nurse should immediately suction the oral and nasal passages to clear any potential airway obstruction or mucus. This intervention aims to restore normal airﬂow and ensure adequate ventilation for the infant.

A. "Move objects away from the client." B. "Restrain the client." C. "Place the client on his back." D. "Insert a padded tongue blade into the client's moutH."

Correct Answer is A

Explanation

Choice A reason: "Move objects away from the client." This instruction should be included in the teaching because it can prevent injury and protect the client from harm during a seizurE.

Choice B reason: "Restrain the client." This instruction should not be included in the teaching because it can cause injury and increase agitation and anxiety for the client during a seizurE.

Choice C reason: "Place the client on his back." This instruction should not be included in the teaching because it can increase the risk of aspiration and airway obstruction for the client during a seizurE.

Choice D reason: "Insert a padded tongue blade into the client's moutH." This instruction should not be included in the teaching because it can cause injury and choking for the client during a seizurE.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. Which immediate intervention should the practical nurse (PN) implement?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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