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: Calling for an assistant allows the nurse to ensure the client receiving tracheostomy care is safe and monitored while responding to the code blue, which is a priority emergency situation.

Choice B reason: Closing the room door does not address the need for assistance with the ongoing procedure and the emergency.

Choice C reason: Finishing the procedure may delay the nurse's response to the code blue, which requires immediate attention.

Choice D reason: Responding to the code without ensuring the current client is safe can lead to potential complications during tracheostomy care.

A. Mononucleosis. B. Herpes simplex virus. C. Syphilis. D. Toxic shock syndrome.

Correct Answer is C

Explanation

Choice A reason: Mononucleosis typically presents with fever, sore throat, and lymphadenopathy but does not commonly cause a rash on the hands and feet.

Choice B reason: Herpes simplex virus usually causes painful vesicular lesions rather than a diffuse rash on the hands and feet.

Choice C reason: Syphilis can present with a fever, sore throat, and a characteristic rash on the hands, palms, and soles of the feet, particularly in the secondary stage of the infection.

Choice D reason: Toxic shock syndrome is associated with high fever, rash, and shock, but the rash is not typically confined to the hands and feet.

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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 performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

Correct Answer is A

Explanation

A female client presents to the clinic with a fever and sore throat as well as a rash on the hands, palms, and the soles of the feet. The client reports having intercourse once with a new partner approximately 8 weeks ago. Which condition should the nurse suspect?

Correct Answer is C

Explanation

During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

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?

The nurse observes an unlicensed assistive personal (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which activity should the nurse assign to the UAP?

The nurse is teaching a male adolescent recently diagnosed with type 1 diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate the effectiveness of the teaching?

The school nurse is preparing a teaching pamphlet in response to requests from parents regarding an outbreak of pinworms at the local preschool. Which information about the most commonly prescribed medication, mebendazole, should be included?

The nurse knows that a medication has the side effect of orthostatic hypotension. Which assessment should the nurse make before administering the medication?