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 ["B","C"]
Explanation
Choice A reason: "I may experience urinary incontinence." This statement does not indicate the need for additional teaching. It is a correct statement that reflects an understanding of one of the possible symptoms of MS. Urinary incontinence is caused by nerve damage that affects bladder control.
Choice B reason: "I should not exercise because this may trigger an exacerbation." This statement indicates the need for additional teaching. It is an incorrect statement that reflects a misconception about exercise and MS. Exercise does not cause or worsen MS relapses but rather has many benefits for people with MS, such as improving muscle strength, balance, mobility, mood, and quality of life.
Choice C reason: "I should alternate the eye patch every other day to help with the double vision." This statement indicates the need for additional teaching. It is an incorrect statement that reflects a misunderstanding of how to manage double vision, which is another possible symptom of MS. Alternating the eye patch every other day does not help with double vision, but rather may cause eye fatigue or confusion. The correct way to use an eye patch is to wear it on one eye only when needed, such as when reading or driving.
Choice D reason: "I may experience visual disturbances." This statement does not indicate the need for additional teaching. It is a correct statement that reflects an awareness of another possible symptom of MS. Visual disturbances may include blurred vision, loss of color vision, pain in one eye, or partial or complete blindness.
Choice E reason: "I need to check the water temperature before I take a bath." This statement does not indicate the need for additional teaching. It is a correct statement that reflects a precaution that people with MS should take. Checking the water temperature before taking a bath can prevent burns or scalds, as some people with MS may have reduced sensation or numbness in their skin.
Correct Answer is ["C","D"]
Explanation
Choice A reason: The inability to take risks is not a quality of an effective nurse leader, as it may limit the leader's potential for growth, innovation, and improvement. Effective nurse leaders are willing to take calculated risks that are based on evidence, experience, and intuition. They are also able to learn from their mistakes and failures and use them as opportunities for development.
Choice B reason: Never consider being a follower is not a quality of an effective nurse leader, as it may indicate a lack of flexibility, collaboration, and respect for others. Effective nurse leaders are able to adapt to different situations and roles, depending on the needs and goals of the team. They are also able to recognize the strengths and contributions of their followers and empower them to achieve their full potential.
Choice C reason: The ability to set priorities is a quality of an effective nurse leader, as it helps the leader to focus on the most important and urgent tasks and goals. Effective nurse leaders are able to identify the needs and expectations of their clients, staff, and organization, and allocate their time, resources, and energy accordingly. They are also able to delegate tasks appropriately and efficiently.
Choice D reason: Integrity is a quality of an effective nurse leader, as it reflects the leader's honesty, trustworthiness, and ethical standards. Effective nurse leaders are able to act in accordance with their values and principles, and uphold the professional code of conduct. They are also able to communicate openly and transparently, and accept responsibility and accountability for their actions and decisions.
Choice E reason: Critical care certification is not a quality of an effective nurse leader, as it is not a requirement or a guarantee for leadership success. Critical care certification is a credential that demonstrates the nurse's knowledge and competence in providing care to critically ill patients. While it may enhance the nurse's clinical skills and confidence, it does not necessarily reflect the nurse's leadership skills or abilities. Effective nurse leaders can come from various backgrounds and specialties, as long as they have the necessary qualities and attributes that enable them to lead others effectively.
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