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 ["A","E"]
Explanation
The correct answers are:
a) Transport a urine culture sample to the laboratory. Correct
This is a client care intervention that the PN can assign to the UAP. Transporting a urine culture sample to the laboratory is a routine and non-invasive task that does not require clinical judgment or skill. The UAP should follow the standard precautions and protocols for handling and labeling the specimen.
b) Obtain a post-voided residual (PVR) volume.
This is not a client care intervention that the PN can assign to the UAP. Obtaining a post-voided residual (PVR) volume is a procedure that requires clinical judgment and skill, as it involves using a bladder scanner or catheterizing the client to measure the amount of urine left in the bladder after voiding.
The UAP is not trained or authorized to perform this task, and it should be done by the PN or another licensed nurse.
c) Teach the client with fluid restrictions how to measure urine output.
This is not a client care intervention that the PN can assign to the UAP. Teaching the client with fluid restrictions how to measure urine output is an educational activity that requires clinical judgment and skill, as it involves assessing the client's learning needs, providing clear and accurate instructions, and evaluating the client's understanding and compliance. The UAP is not trained or authorized to perform this task, and it should be done by the PN or another licensed nurse.
d) Irrigate an indwelling urinary catheter for a client with bladder suspension.
This is not a client care intervention that the PN can assign to the UAP. Irrigating an indwelling urinary catheter for a client with bladder suspension is a procedure that requires clinical judgment and skill, as it involves inserting sterile fluid into the bladder through the catheter to flush out any clots, debris, or bacteria. The UAP is not trained or authorized to perform this task, and it should be done by the PN or another licensed nurse.
e) Empty bedside drainage unit for a client with indwelling urinary catheter. Correct
This is a client care intervention that the PN can assign to the UAP. Emptying bedside drainage unit for a client with indwelling urinary catheter is a routine and non-invasive task that does not require clinical judgment or skill. The UAP should follow the standard precautions and protocols for emptying, measuring, and recording the urine output.
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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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