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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale
The patient lying in bed with their head elevated to 35 degrees while eating could pose a risk for aspiration, especially for a patient with Huntington’s disease. Huntington’s disease is a neurodegenerative disorder that can cause difficulties with swallowing and motor control.
Therefore, it is recommended that the patient be as upright as possible, ideally in a seated position, during meals to reduce the risk of aspiration.
Choice B rationale

Providing thickened liquids is a common intervention for patients with Huntington’s disease who have difficulty swallowing. Thickened liquids are easier to control and swallow, reducing the risk of aspiration.
Choice C rationale
Not rushing the patient in eating each bite is a recommended practice. Patients with Huntington’s disease often have difficulty with motor control, including swallowing. Allowing the patient to take their time can help prevent choking and aspiration.
Choice D rationale
Ensuring that the patient’s food is minced is another recommended practice for patients with Huntington’s disease. Minced food is easier to chew and swallow, which can help prevent choking and aspiration.

Correct Answer is ["2 "]

Explanation

Step 1 is: To calculate the rate at which the IV pump should be set to deliver the PRBCs, we need to divide the total volume of PRBCs by the total time for administration.

Step 2 is: Convert the time for administration from hours to minutes because the rate is typically set in mL/min. So, 3 hours is equivalent to 180 minutes.

Step 3 is: Now, divide the total volume of PRBCs (350 mL) by the total time for administration (180 min). So, the calculation is 350 mL ÷ 180 min.

Step 4 is: The final calculated answer is approximately 1.94 mL/min. However, IV pumps typically only allow whole numbers, so we would round this to 2 mL/min.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is precepting a new nurse who is caring for a patient with a history of Huntington’s disease. The new nurse is preparing to feed the patient lunch. What action by the new nurse would cause the precepting nurse to intervene?

Correct Answer is A

Explanation

A nurse is administering a 350 mL unit of PRBCs over 3 hours to a client diagnosed with anemia. The nurse should set the IV pump to deliver how many mL/hr?

Correct Answer is ["2 "]

Explanation

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