The nurse is providing education to a client who is newly diagnosed with Multiple Sclerosis (MS). Which client statements indicate the need for additional teaching? SELECT ALL THAT APPLY

“I may experience urinary incontinence.”

“I should not exercise because this may trigger an exacerbation.”

“I need to check the water temperature before I take a bath.”

“I may experience visual disturbances.”

“I should alternate the eye patch every other day to help with the double vision.”

Answer and Explanation

Correct Answer : B,E

Choice A reason:

“I may experience urinary incontinence.” This statement is correct. Urinary incontinence is a common symptom of MS due to the disease’s impact on the nervous system. The client does not need additional teaching regarding this statement.

Choice B reason:

“I should not exercise because this may trigger an exacerbation.” This statement indicates a need for additional teaching. Regular exercise is beneficial for individuals with MS and can help improve strength, mobility, and overall well-being. The nurse should educate the client on safe and appropriate exercise routines.

Choice C reason:

“I need to check the water temperature before I take a bath.” This statement is correct. Clients with MS may have impaired sensation and are at risk for burns if the water is too hot. Checking the water temperature is a necessary precaution.

Choice D reason:

“I may experience visual disturbances.” This statement is correct. Visual disturbances, such as blurred vision or double vision, are common symptoms of MS. The client does not need additional teaching regarding this statement.

Choice E reason:

“I should alternate the eye patch every other day to help with the double vision.” This statement indicates a need for additional teaching. While using an eye patch can help manage double vision, it should be alternated more frequently, typically every few hours, to prevent strain on the covered eye.

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Correct Answer is C

Explanation

Choice A reason:

Assisting the client with active range of motion exercises is important for preventing complications such as contractures and maintaining mobility. However, it is not the priority intervention in the acute phase of a hemorrhagic stroke. The primary focus should be on stabilizing the client and monitoring their condition closely.

Choice B reason:

Maintaining strict bed rest to minimize cerebral blood flow is not appropriate for managing a hemorrhagic stroke. While bed rest may be necessary to prevent further injury, the priority is to monitor the client’s neurological status and vital signs to detect any changes that may indicate worsening of the condition.

Choice C reason:

Monitoring vital signs and neurological status frequently is the priority intervention for a client who has experienced a hemorrhagic stroke. Close monitoring allows the nurse to detect any changes in the client’s condition promptly and take appropriate action. This is crucial for preventing complications and ensuring timely intervention if the client’s condition deteriorates.

Choice D reason:

Administering anticoagulant medications is contraindicated in hemorrhagic stroke because they can exacerbate bleeding. Anticoagulants are used in ischemic stroke to prevent clot formation, but in hemorrhagic stroke, the focus is on controlling bleeding and stabilizing the client.

A. “Insert a padded tongue blade into the client’s mouth.” B. “Restrain the client.” C. “Move objects away from the client.” D. “Place the client on his back.”

Correct Answer is C

Explanation

Choice A reason:

Inserting a padded tongue blade into the client’s mouth is not recommended and can be dangerous. During a seizure, there is a risk of causing injury to the client’s mouth or teeth, and it can also obstruct the airway. The correct approach is to ensure the client’s safety by preventing injury, not by inserting objects into their mouth.

Choice B reason:

Restraining the client during a seizure is not advised. Restraints can cause additional harm and do not prevent the seizure from occurring. Instead, the focus should be on protecting the client from injury by ensuring a safe environment and allowing the seizure to run its course.

Choice C reason:

Moving objects away from the client is a crucial step in ensuring their safety during a seizure. This action helps prevent the client from hitting or injuring themselves on nearby objects. Creating a safe space around the client is one of the primary goals during a seizure to minimize the risk of injury.

Choice D reason:

Placing the client on their back is not recommended during a seizure. Instead, the client should be placed on their side if possible, to help keep the airway clear and reduce the risk of aspiration. This position also allows for better monitoring of the client’s breathing and overall condition.

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The nurse is providing education to a client who is newly diagnosed with Multiple Sclerosis (MS). Which client statements indicate the need for additional teaching? SELECT ALL THAT APPLY

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has experienced a hemorrhagic stroke. Which intervention should the nurse prioritize when providing care to the client?

Correct Answer is C

Explanation

A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

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