The nurse provides 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 should alternate the eye patch every other day to help with the double vision."
"I may experience visual disturbances."
"I need to check the water temperature before I take a bath."
Correct Answer : B,C
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.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A reason: Nurses performing duties outside of the nurses' typical job description is a component that should include nurses. In a disaster situation, nurses may have to assume roles and responsibilities that are beyond their usual scope of practice, such as triage, first aid, or mass casualty management. Nurses should be trained and prepared to perform these duties safely and effectively.
Choice B reason: A plan for comprehensive practice drills is a component that should include nurses. Practice drills are essential for testing and improving the disaster plan, as well as enhancing the skills and confidence of the staff. Nurses should participate in regular and realistic drills that simulate different types of disasters and scenarios.
Choice C reason: Identification of resources to meet anticipated needs for food, water, and supplies is a component that should include nurses. In a disaster situation, the demand for resources may exceed the supply, and the availability of resources may be disrupted or limited. Nurses should be involved in identifying and prioritizing the essential resources that are needed to provide care and support to the clients and staff.
Choice D reason: An internal and external communication plan is a component that should include nurses. In a disaster situation, communication is vital for coordinating actions, sharing information, and providing updates. Nurses should be aware of the communication channels and protocols that are used within and outside the hospital, such as radios, phones, or social media.
Choice E reason: Discharge all surgical clients who are one day or more post-op is not a component that should include nurses. This is not a realistic or appropriate strategy for reducing the hospital's occupancy or workload in a disaster situation. Discharging surgical clients who are still recovering may compromise their health outcomes and increase their risk of complications or readmission.
Correct Answer is B
Explanation
Choice A: Limit fluid intake to prevent incontinence. This is incorrect because limiting fluid intake can lead to dehydration, urinary tract infections, and kidney stones. Fluid intake should be adequate to maintain hydration and flush out bacteria from the urinary tract.
Choice B: Provide regular perineal care to prevent skin breakdown. This is correct because reflex incontinence can cause urine leakage and skin irritation, which can increase the risk of infection and pressure ulcers. Regular perineal care can help keep the skin clean and dry, and prevent complications.
Choice C: Administer hypotonic IV fluids. This is incorrect because hypotonic IV fluids can cause fluid overload, hyponatremia, and cerebral edema. Hypotonic IV fluids are not indicated for clients with reflex incontinence.
Choice D: Teach Kegel exercises to strengthen the pelvic floor. This is incorrect because Kegel exercises are effective for clients with stress or urge incontinence, but not for clients with reflex incontinence. Reflex incontinence is caused by a loss of voluntary control over the bladder due to a spinal cord injury, and Kegel exercises cannot restore this function.
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