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 C
Explanation
Choice A reason: "Diet and exercise is good for you and good for your heart." This statement is true, but it is not the appropriate nursing response. It does not address the client's concerns or provide any specific information about cardiac rehabilitation. It may also sound dismissive or patronizing to the client.
Choice B reason: "It's not unusual to feel that way at first, but once you learn the routine, you'll enjoy it." This statement is empathetic, but it is not the appropriate nursing response. It does not explain the purpose or benefits of cardiac rehabilitation. It may also sound unrealistic or optimistic to the client.
Choice C reason: "Cardiac rehabilitation cannot undo the damage to your heart, but it can help you get back to your previous level of activity safely." This statement is the appropriate nursing response. It acknowledges the client's condition and provides factual information about cardiac rehabilitation. It also emphasizes the positive outcomes of cardiac rehabilitation, such as improving physical function, reducing symptoms, and preventing further complications.
Choice D reason: "Your doctor is the expert here, and I'm sure he would only recommend what is best for you." This statement is respectful, but it is not the appropriate nursing response. It does not answer the client's question or provide any education about cardiac rehabilitation. It may also sound evasive or deferential to the client.
Correct Answer is D
Explanation
Choice A: Administer corticosteroids. This is incorrect because corticosteroids are used to reduce inflammation and suppress the immune system, but they do not directly affect venous return, stiffness, or muscle strength and endurance.
Choice B: Turn and reposition every 2 hours. This is incorrect because turning and repositioning are important to prevent pressure ulcers and promote circulation, but they are not sufficient to maintain muscle strength and endurance. The client also needs active or passive exercises to prevent muscle atrophy and contractures.
Choice C: Administer interferon. This is incorrect because interferon is a type of immunomodulator that can reduce the frequency and severity of relapses in multiple sclerosis, but it does not directly affect venous return, stiffness, or muscle strength and endurance.
Choice D: Encourage range-of-motion exercises. This is correct because range-of-motion exercises can help increase venous return, prevent stiffness, and maintain muscle strength and endurance in clients with multiple sclerosis. Range-of-motion exercises can be performed actively by the client or passively by the nurse or a caregiver. They should be done at least twice a day to prevent complications such as contractures, spasticity, and pain.
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