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.
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. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale
Dimming the lighting in the client's room helps reduce photophobia and headaches, which are common symptoms in viral meningitis.
Choice A rationale
Monitoring temperature every 6 hours is not as frequent as needed. Frequent monitoring is crucial due to the risk of rapid changes in condition.
Choice C rationale
Contact precautions are not necessary for viral meningitis, as it is not as contagious as bacterial meningitis. Standard precautions are generally sufficient.
Choice D rationale
Measuring intake and output every 8 hours is standard, but it is not specific to the needs of a viral meningitis patient like controlling environmental stimuli.
Correct Answer is A
Explanation
Choice A rationale
Hand hygiene is critical for preventing the spread of MRSA. Washing hands removes any bacteria that may have been picked up during contact with the infected client or surfaces in the room. Proper handwashing technique includes using soap and water or an alcohol-based hand sanitizer for at least 20 seconds.
Choice B rationale
Reusing unsoiled gloves is not recommended because MRSA can persist on surfaces and gloves for prolonged periods. Changing gloves each time entering the room ensures any contamination is not transferred to different areas or patients.
Choice C rationale
Wearing a gown protects the caregiver’s clothing from contamination when assisting with activities like bathing. Gowns act as a barrier to prevent MRSA from contacting the caregiver's skin or clothes and being carried outside the patient’s room.
Choice D rationale
Taking the client outside the room increases the risk of spreading MRSA to others. While a mask may protect against respiratory droplets, it does not prevent the transmission of MRSA via contact with contaminated surfaces or the patient’s skin.
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