The nurse is creating an education plan for a client who has a recent diagnosis of Multiple Sclerosis (MS). Which of the following interventions should the nurse include in the client's plan?
Provide total assistance with all ADLs
Order a low-residue diet
Encourage client to void every hour
Instruct the client on daily muscle stretching
The Correct Answer is D
Choice A reason: Providing total assistance with all ADLs is not an intervention that should be included in the client's plan. ADLs are activities of daily living, such as bathing, dressing, eating, and toileting. Providing total assistance with all ADLs can reduce the client's independence and self-esteem, and increase their dependence and learned helplessness. The nurse should encourage and assist the client to perform as much as they can by themselves and provide partial or intermittent assistance only when needed.
Choice B reason: Ordering a low-residue diet is not an intervention that should be included in the client's plan. A low-residue diet is a type of diet that limits foods that are high in fiber or indigestible material, such as whole grains, nuts, seeds, fruits, and vegetables. A low-residue diet may be recommended for clients who have inflammatory bowel disease (IBD), diverticulitis, or bowel obstruction, as it can reduce bowel frequency and irritation. However, it is not indicated for clients who have MS, unless they have other comorbidities that require it. A balanced diet that includes adequate fiber, fluids, and nutrients is more beneficial for clients who have MS.
Choice C reason: Encouraging the client to void every hour is not an intervention that should be included in the client's plan. Voiding every hour can be inconvenient and impractical for the client, and may not address their bladder problems effectively. MS can cause bladder dysfunction, such as urinary urgency, frequency, incontinence, or retention, due to nerve damage that affects bladder control. The nurse should assess the type and severity of the bladder dysfunction, and provide appropriate interventions, such as medication, catheterization, pelvic floor exercises, or bladder training.
Choice D reason: Instructing the client on daily muscle stretching is an intervention that should be included in the client's plan. Muscle stretching is a type of exercise that involves extending or elongating a muscle or group of muscles to their full length. Muscle stretching can help prevent or relieve muscle spasticity, stiffness, pain, or contractures that may occur in clients who have MS. The nurse should teach the client how to perform muscle stretching safely and correctly, and encourage them to do it daily or as prescribed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: The AP's ability to complete the task without assistance is not one of the five rights of delegation. The nurse is responsible for providing adequate supervision and guidance to the AP, and ensuring that the task is done correctly and safely.
Choice B reason: The AP's ability to prioritize is not one of the five rights of delegation. The nurse is responsible for assigning tasks based on their urgency and importance and communicating clear expectations and deadlines to the AP.
Choice C reason: The AP's rapport with clients is not one of the five rights of delegation. The nurse is responsible for maintaining a therapeutic relationship with clients and respecting their preferences and needs.
Choice D reason: The AP has the knowledge and skill to perform the task is one of the five rights of delegation. The nurse is responsible for assessing the AP's competence and readiness to perform the task, and providing appropriate training and feedback if needed.
Correct Answer is C
Explanation
Choice A reason: Completing a survey of the various ethnicities represented in the nurse's community is a good way to learn about diversity, but it is not the first step in developing cultural competence. The nurse should first examine their own cultural background and biases, and how they affect their interactions with clients.
Choice B reason: Studying the beliefs and traditions of persons living in other cultures is a valuable way to gain knowledge and understanding, but it is not the first step in developing cultural competence. The nurse should first be aware of their own cultural values and assumptions, and how they influence their perceptions and judgments.
Choice C reason: Considering how the nurse's own personal beliefs and decisions are reflective of their culture is the first step in developing cultural competence. The nurse should recognize that culture is not only about ethnicity, but also about age, gender, religion, education, socioeconomic status, and other factors. The nurse should also acknowledge that culture is dynamic and complex and that each person has a unique cultural identity.
Choice D reason: Inviting a family from another culture to join the nurse for an event is a nice way to show respect and interest, but it is not the first step in developing cultural competence. The nurse should first develop self-awareness and sensitivity, and avoid making stereotypes or generalizations about other cultures.
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