A nurse is assisting with the admission of a client who has limited mobility. Which of the following actions is the nurse's priority?

Demonstrate to the client how to use the signaling device.

Explain the facility's meal schedule

Demonstrate to the client how to use the television.

Explain the medication administration schedule.

Answer and Explanation

The Correct Answer is A

A. Demonstrate to the client how to use the signaling device: Teaching the client how to use the call light is the priority because it ensures they can easily ask for assistance, especially with limited mobility. Immediate access to help reduces the risk of falls, injury, and delays in meeting urgent needs.

B. Explain the facility's meal schedule: While it is important for the client to know when meals are served, this information does not impact their immediate safety or ability to get assistance when needed, making it a lower priority than teaching about the call light.

C. Demonstrate to the client how to use the television: Teaching about the television promotes comfort but is nonessential for safety or urgent needs. Comfort measures can be addressed after critical safety interventions have been completed.

D. Explain the medication administration schedule: Understanding medication schedules is important for client education and adherence, but ensuring the ability to call for help is more immediately critical, especially in a client with limited mobility.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

Deep tendon patellar reflex: The client's deep tendon reflexes improved from being hyperreflexive at 4+ to normal at 2+ without clonus on Day 2. This is a positive sign because hyperreflexia increases seizure risk in preeclampsia, and normalization indicates stabilization of neurological irritability.
Blood pressure: Although still elevated, the blood pressure decreased from 166/110 mm Hg to 152/90 mm Hg by Day 2. While not normal yet, the trend toward lower values represents improvement in controlling the severe hypertension associated with preeclampsia.
Heart rate: The client's heart rate increased slightly from 72/min to 90/min. While still within normal range, this change reflects a more responsive and stable cardiovascular status, and there are no signs of bradycardia or distress, supporting mild improvement.
Edema: The client continues to have +3 pitting edema bilaterally, with no reported reduction compared to the initial assessment. Persistent severe edema suggests that fluid balance issues from preeclampsia have not yet improved and still require active management.

A. Recommend frequent hot baths. B. Encourage the client to restrict performing range-of-motion exercises. C. Monitor the client's ability to perform ADLS. D. Initiate contact precautions.

Correct Answer is C

Explanation

A. Recommend frequent hot baths: Hot baths can exacerbate symptoms in clients with multiple sclerosis by increasing fatigue and worsening muscle weakness due to a rise in core body temperature. Clients are usually advised to avoid overheating and use cooling strategies instead to manage their symptoms.

B. Encourage the client to restrict performing range-of-motion exercises: Range-of-motion exercises are important in maintaining joint flexibility, muscle strength, and overall mobility. Restricting these exercises could lead to increased stiffness, weakness, and decreased functional ability in clients with multiple sclerosis.

C. Monitor the client's ability to perform ADLs: Monitoring the client's ability to perform activities of daily living is essential because multiple sclerosis often leads to progressive physical limitations. Regular assessment helps in planning appropriate interventions, promoting independence, and adjusting care as the disease progresses.

D. Initiate contact precautions: Contact precautions are not necessary for clients with multiple sclerosis because it is not an infectious disease. Multiple sclerosis is an autoimmune, neurodegenerative condition that requires supportive care rather than infection control measures.

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A nurse is assisting with the admission of a client who has limited mobility. Which of the following actions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is continuing to assist with the care of the client. For each finding, click to specify if the finding indicates that the client's condition has improved or has not changed.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

A nurse is assisting with planning care for a client who has a new diagnosis of multiple sclerosis. Which of the interventions should the nurse recommend?

Correct Answer is C

Explanation

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