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 C

Explanation

An oil retention enema is used to soften the stool and lubricate the rectum, making it easier to pass the stool. It is usually oil-based and contains 90-120 ml of solution³.
The temperature of the enema solution aﬀects the eﬀectiveness and comfort of the procedure. If the solution is too hot or cold, it can cause pain, cramps, or damage to the rectal tissue³. If the solution is too warm, it can also stimulate peristalsis and cause the client to expel the enema before it has time to work⁴.
The ideal temperature for an enema solution is close to the client’s body temperature, which is around 98°F or 36°C. This temperature ensures that the solution is comfortable and does not cause adverse reactions³⁴.

Option A is incorrect because the client’s comfort level may not reﬂect the optimal temperature for the

enema.

Option B is incorrect because the temperature of the enema does aﬀect its eﬀectiveness and safety. Option D is incorrect because the temperature is too high and can cause harm to the client.

A. Provide total assistance with all ADLs B. Order a low-residue diet C. Encourage client to void every hour D. Instruct the client on daily muscle stretching

Correct Answer is D

Explanation

Choice A reason: Providing total assistance with all ADLs is not an appropriate intervention for the client because it can decrease the client's independence and self-esteem, and increase the risk of complications such as pressure ulcers, contractures, and infections. The client should be encouraged to perform as much self-care as possible, with assistance as needeD.

Choice B reason: Ordering a low-residue diet is not an appropriate intervention for the client because it can cause constipation, which can worsen the client's bowel function and quality of lifE. The client should consume a balanced diet that includes adequate fiber, fluids, and nutrients.

Choice C reason: Encouraging the client to void every hour is not an appropriate intervention for the client because it can disrupt the client's normal bladder function and increase the risk of urinary tract infections. The client should follow a regular bladder training program that involves voiding at scheduled intervals, using pelvic floor exercises, and managing fluid intakE.

Choice D reason: Instructing the client on daily muscle stretching is an appropriate intervention for the client because it can improve the client's mobility, flexibility, and range of motion, as well as prevent muscle spasticity, stiffness, and pain. The client should perform gentle stretching exercises under the guidance of a physical therapist or nursE.

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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

An oil retention enema is prescribed for a hospitalized client. The practical nurse (PN) should administer the enema solution at which temperature?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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