Which action should the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder?

Choice A reason: Asking the nursing assistant to determine if Marvin can safely sit in a bedside chair is not appropriate. Safety assessments, especially for patients with recent neurological events, should be done by a registered nurse or a physical therapist. This ensures that any nuanced clinical signs indicating instability or risk are recognized and addressed promptly.
Choice B reason: Passive range of motion (ROM) exercises are essential for patients with hemiplegia to prevent complications such as muscle atrophy, joint contractures, and decreased circulation. Regularly performing these exercises can maintain the health of the muscles and joints, promote better blood flow, and help in maintaining some degree of flexibility in the affected limbs.
Choice C reason: Assessing neurologic status is crucial in patients who have had a recent stroke and received tPA treatment. Frequent neurologic assessments help in monitoring for any changes or signs of deterioration. This includes checking consciousness, pupil response, motor function, and sensory perception. Changes in these parameters can indicate complications or the need for immediate medical interventions.
Choice D reason: Coordinating with speech therapy for a swallowing evaluation is essential because Marvin has dysphagia. Swallowing assessments by a speech therapist can determine the patient's ability to swallow safely and the appropriate dietary modifications needed to prevent aspiration, a common risk in patients with dysphagia. This is vital to prevent pneumonia or other respiratory complications.
Choice E reason: Using pillows and positioning devices to maintain proper body alignment is important in preventing complications such as pressure ulcers, muscle contractures, and discomfort. Proper positioning can also assist in maintaining better respiratory function and overall comfort. It also prevents the development of deformities and promotes functional posture, which is especially important for patients with hemiplegia.
Choice F reason: Pulling on his arm to position him on his side is inappropriate and can cause injury, especially in a patient with hemiplegia. This technique can lead to shoulder dislocations or increased pain. Instead, proper repositioning techniques using assistive devices and help from additional staff members should be employed to ensure safe and effective movement of the patient.

Choice A reason: Checking the blood pressure and pulse is important as part of the routine monitoring of vital signs to assess the patient's hemodynamic status. However, it is not the first action to take following a thyroidectomy. Ensuring that the patient's airway is clear and that there is no respiratory distress is paramount, as any compromise in the airway can lead to life-threatening situations. Blood pressure and pulse can be checked after confirming the patient is breathing properly.
Choice B reason: Observing the dressing for bleeding is also important because post-operative bleeding can be a serious concern. However, this action should follow the assessment of the patient's airway. If the patient is experiencing respiratory distress, addressing the airway takes precedence. Once it is confirmed that the airway is clear, then the nurse can check for bleeding and ensure the dressing is intact.
Choice C reason: Supporting the patient's head with pillows is beneficial for comfort and proper positioning, especially to avoid strain on the surgical site. However, positioning should not be the first priority. Ensuring that the patient's airway is clear and that there is no respiratory compromise is the most urgent concern. Proper positioning can be done after confirming that the patient is breathing adequately.
Choice D reason: Assessing the patient's respiratory effort is the first and most critical action. Following a thyroidectomy, there is a risk of respiratory complications due to potential swelling, bleeding, or damage to the trachea and surrounding structures. Immediate assessment of respiratory effort ensures that the airway is patent and the patient is not in respiratory distress. This step is crucial to prevent hypoxia and other serious complications.