The nurse is completing the admission assessment of a client with multiple sclerosis (MS). Which finding(s) should be reported to the healthcare provider immediately? Select all that apply.

Tinnitus.

Tachycardia.

Tremors.

Paresthesia.

Fever.

Answer and Explanation

Correct Answer : B,E

Choice A reason: Tinnitus is not an immediate concern in the context of multiple sclerosis.

Choice B reason: Tachycardia should be reported immediately as it could indicate an underlying cardiovascular issue or autonomic dysfunction.

Choice C reason: Tremors are a common symptom of multiple sclerosis and do not require immediate reporting unless there is a significant change.

Choice D reason: Paresthesia is also a common symptom of multiple sclerosis and does not require immediate reporting unless there is a significant change.

Choice E reason: Fever should be reported immediately as it can indicate an infection, which can exacerbate multiple sclerosis symptoms.

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Correct Answer is A

Explanation

Choice A reason: Administering cefazolin, an antibiotic, is a priority to prevent or treat potential infections in the immediate postoperative period.

Choice B reason: Completing a CBC in the morning is important for ongoing assessment but is not an immediate priority.

Choice C reason: Advancing the diet as tolerated is important but can be done after ensuring infection prevention.

Choice D reason: Straight catheterization is necessary if the client is unable to void but is not the immediate priority compared to preventing infection.

A. Apply petroleum jelly to the child's nose and lips. B. Use a topical lidocaine analgesic for cracked lips. C. Ask the mother what she usually uses on the child's lips and nose. D. Use a water soluble lubricant on affected oral and nasal mucosa.

Correct Answer is D

Explanation

Choice A reason: Applying petroleum jelly is not recommended because it is not water-soluble and can potentially be inhaled into the lungs, posing a risk.

Choice B reason: Using a topical lidocaine analgesic is not suitable for cracked lips and nares, as it is intended for pain relief rather than moisturizing.

Choice C reason: Asking the mother what she usually uses on the child's lips and nose is helpful for gathering information but does not provide an immediate intervention.

Choice D reason: Using a water soluble lubricant is appropriate because it helps to moisturize the dry and cracked areas without posing a risk of inhalation, ensuring the child's comfort and safety.

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The nurse is completing the admission assessment of a client with multiple sclerosis (MS). Which finding(s) should be reported to the healthcare provider immediately? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

Correct Answer is A

Explanation

While caring for a toddler receiving oxygen via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?

Correct Answer is D

Explanation

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The nurse is completing the admission assessment of a client with multiple sclerosis (MS). Which finding(s) should be reported to the healthcare provider immediately? Select all that apply.