The nurse is creating a plan of care for a client who has a recent diagnosis of multiple sclerosis. Which of the following should the nurse include in the client’s care plan?
Instruct the client on daily muscle stretching.
Order a low-residual diet.
Encourage the client to void every hour.
Provide total assistance with all activities of daily living.
The Correct Answer is A
Choice A rationale
Instructing the client on daily muscle stretching can help alleviate and relax muscle spasms, which is beneficial for a client diagnosed with multiple sclerosis.
Choice B rationale
Ordering a low-residual diet is not typically a part of the care plan for a client diagnosed with multiple sclerosis.
Choice C rationale
Encouraging the client to void every hour may not be necessary for a client diagnosed with multiple sclerosis, unless there are specific urinary symptoms present.
Choice D rationale
Providing total assistance with all activities of daily living may not be necessary for a client diagnosed with multiple sclerosis, as the level of assistance required can vary greatly depending on the severity of the disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is: = b. Prostaglandins
Choice A: Carbonic anhydrase inhibitors: These medications can be used for glaucoma, but they are not typically the first-line treatment due to potential side effects.
Choice B: Prostaglandins (Correct Answer) These are often the preferred initial medication for glaucoma because they are effective at lowering eye pressure, have minimal systemic side effects, and are typically used once daily.
Choice C: Alpha-agonists: These medications can be used as an adjunct to other glaucoma medications but are not usually the first choice due to potential side effects like dry mouth and fatigue.
Choice D: Beta-blockers: While once a common first-line treatment, beta-blockers have been largely replaced by prostaglandins due to potential side effects like slowed heart rate and worsened breathing problems.
Correct Answer is C
Explanation
Choice C rationale
When providing care for a comatose patient, a nurse should evaluate motor responses by observing the patient’s response to painful stimuli. This can be done by applying a painful stimulus, such as a trapezius pinch or nailbed pressure, and observing the patient’s motor response. Purposeful or semi-purposeful movements, such as localizing or withdrawing from pain, can provide valuable information about the patient’s level of consciousness and neurological function.
Choice A rationale
The Romberg test is used to evaluate balance and is not typically used to evaluate motor responses in a comatose patient.
Choice B rationale
Assessing the patient’s sensitivity to temperature and touch can provide information about sensory function, but it does not directly evaluate motor responses.
Choice D rationale
Observing the reaction of pupils to light can provide information about cranial nerve function, but it does not directly evaluate motor responses.
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