A nurse is assisting with the admission of a client who has multiple sclerosis.
Which of the following actions is the priority for the nurse to take?

Discuss the possible changes in family roles.

Encourage the client to verbalize their feelings.

Determine the client's ability to see the buttons on the call light.

Assist the client and family in locating a community support group.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Discussing changes in family roles is important but is not the immediate priority upon admission. This can be addressed once the client's immediate needs are met.

Choice B rationale

Encouraging verbalization of feelings is crucial for mental health support but is not the most urgent action during admission.

Choice C rationale

Determining the client's ability to see the buttons on the call light ensures their immediate safety and ability to call for help, making it the priority.

Choice D rationale

Assisting with locating a community support group is essential for long-term support but is not the first priority upon admission. .

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Correct Answer is C

Explanation

Choice A rationale

Placing throw rugs on the floor increases the risk of falls, which is particularly dangerous for clients with Alzheimer's disease due to potential mobility and cognitive impairments. Fall prevention measures are critical in their care.

Choice B rationale

Leaving the television on can contribute to sensory overload and confusion in clients with Alzheimer's disease. A calm and structured environment with minimal distractions is more beneficial for their cognitive function and well-being.

Choice C rationale

Installing locks at the top of doors helps prevent clients with Alzheimer's disease from wandering and ensures their safety. This modification addresses the common issue of wandering and helps keep the client secure in their environment.

Choice D rationale

Scheduling alternate caregivers is important for managing caregiver fatigue but is not directly related to environmental modifications in the home. Caregiver support is crucial, but the focus here is on physical safety within the home environment.

A. Rotate the jejunostomy tube once per day. B. Administer the feeding solution at a cold temperature. C. Elevate the head of the client's bed for 1 hr after the feeding. D. Flush the tube with 90 mL of sterile water before and after the feeding.

Correct Answer is C

Explanation

Choice A rationale

Rotating the jejunostomy tube daily is not necessary and may cause unnecessary discomfort or complications.

Choice B rationale

Administering the feeding solution at a cold temperature can cause abdominal cramping and discomfort. It should be given at room temperature.

Choice C rationale

Elevating the head of the client's bed for 1 hour after feeding helps prevent aspiration, a serious complication of enteral feedings.

Choice D rationale

Flushing the tube with 90 mL of sterile water is excessive; the standard practice is to use 30-60 mL to clear the tube before and after feedings. .

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A nurse is assisting with the admission of a client who has multiple sclerosis.Which of the following actions is the priority for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about environmental modifications in the home with a family member of a client who has Alzheimer's disease.Which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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A nurse is assisting with the admission of a client who has multiple sclerosis.
Which of the following actions is the priority for the nurse to take?