The nurse is preparing for discharge a client with a history of celiac disease who now has developed multiple sclerosis. Which instruction is most important for the nurse to include in the discharge teaching plan?

Take prescribed cortisone accurately.<br>

Increase daily intake of sodium in diet.

Avoid extreme environmental temperatures.

Use a walker when weakness occurs

Answer and Explanation

The Correct Answer is C

Rationale

A. It's crucial for the client to adhere strictly to the prescribed dosage and schedule to maximize therapeutic benefits and minimize potential side effects. However, temperature regulation is priority

B. Celiac disease requires strict adherence to a gluten-free diet to prevent intestinal damage, while multiple sclerosis management may involve dietary strategies to manage symptoms like fatigue or bladder dysfunction. However, increasing sodium intake generally is not a primary concern unless there are specific indications related to multiple sclerosis symptoms or medication effects.

C. Temperature sensitivity is common in multiple sclerosis, and exposure to extreme heat or cold can exacerbate symptoms such as fatigue, weakness, and cognitive dysfunction. Managing environmental temperature exposure is crucial to minimizing symptom exacerbation and maintaining comfort and safety.

D. Mobility aids, such as walkers, can assist individuals with multiple sclerosis during periods of weakness or impaired balance. Using a walker appropriately can help prevent falls and promote safe mobility. However, this instruction may be more specific to managing symptoms of multiple sclerosis rather than addressing the complex dietary needs associated with celiac disease.

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Correct Answer is A

Explanation

Rationale

A. In the early phase following a burn injury, there is increased capillary permeability due to the release of inflammatory mediators. This results in fluid shifting from the intravascular space into the interstitial space (capillary leaking), leading to hypovolemia and decreased tissue perfusion. Administering crystalloid fluids helps to restore intravascular volume (fluid resuscitation) and improve tissue perfusion.

B. Burn injuries can lead to increased evaporative water loss through damaged skin (insensible water loss). Crystalloid fluids help to replace this lost fluid and maintain adequate hydration status in the client.

C. In severe burn injuries, there may be a need for blood transfusions due to hemorrhage or ongoing blood loss. Crystalloid fluids can help to extend plasma volume temporarily until blood products are available for transfusion, thereby supporting circulatory stability.

D. Burn injuries can disrupt electrolyte balance due to fluid shifts and tissue damage. Crystalloid fluids contain electrolytes (such as sodium and chloride) that help to restore and maintain electrolyte balance in the body.

A. An adult with alcoholism, cirrhosis, and hepatic encephalopathy. B. An older adult who is scheduled for foot amputation due to diabetes complications. C. An adult who is one day postoperative for a laparoscopic cholecystectomy. D. An older client who is one day postoperative with a colostomy for colon cancer.

Correct Answer is C

Explanation

Rationale

A. This client may require complex care related to liver disease and alcoholism, likely exceeding the scope of practice for a PN.

B. While this client requires specialized wound care and diabetes management, the tasks involved may be appropriate for a PN under RN supervision.

C. This client's care typically involves routine postoperative monitoring and interventions that are suitable for a PN under RN supervision.

D. This client requires specialized ostomy care and postoperative monitoring, which can generally be managed by a PN under RN supervision.

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The nurse is preparing for discharge a client with a history of celiac disease who now has developed multiple sclerosis. Which instruction is most important for the nurse to include in the discharge teaching plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

Correct Answer is C

Explanation

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having unprotected sex. Which response should the nurse provide?

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A client taking temazepam informs the nurse of plans to quit taking the medication due to feelings of "hungover" the next day. Which action should the nurse implement?

When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

A older adult client tells the nurse that of having a high-density lipoprotein (HDL) level of 85 mg/dL (2.2 mmol/L). Which action should the nurse take? Reference Range: High Density Lipoproteins (HDL) [greater than 45 mg/dL (greater than 0.75 mmol/L)]