A nurse is contributing to the plan of care for a client who has multiple sclerosis. The nurse should recommend including which of the following interventions in the plan of care to assist the client in overcoming barriers related to this condition?
Establish alternatives to verbal conversation.
Use the numbers on a clock to describe the position of food on the client's plate.
Touch the client's arm before beginning to speak.
Provide the client with large-handled eating utensils.
The Correct Answer is D
A: Alternative communication methods are more applicable to clients with severe speech or cognitive impairments, which are not universally present in multiple sclerosis.
B: Using clock numbers to describe food placement is typically recommended for visually impaired clients, not specifically for those with multiple sclerosis.
C: Touching the client's arm before speaking is a technique used for clients with hearing impairments.
D: Multiple sclerosis can cause fine motor skill impairment and muscle weakness. Providing large-handled utensils can help maintain independence in eating by making it easier to grip and use utensils.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Determine the need for additional providers: Determining the need for additional providers is typically the responsibility of the hospital administration or incident command team, not the unit nurse.
B. Act as a spokesperson to provide information to the media: Communication with the media is managed by designated public relations personnel or a hospital spokesperson, not the unit nurse.
C. Recommend to the provider a list of clients for early discharge: The unit nurse is responsible for assessing which clients are stable enough for discharge and communicating these recommendations to the provider. This helps prioritize bed availability and ensures appropriate allocation of resources during a disaster.
D. Decide which clients should be transported for a higher level of care: This decision is typically made by the disaster management team or the provider, with input from the nurse. Nurses may report clinical details to help inform the decision but do not make the final determination.
Correct Answer is C
Explanation
A. Reevaluating for an ET cuff leak is important but not the immediate priority when the cause of the alarm is unknown, and the client is in distress. It is more important to ensure the client is receiving adequate ventilation.
B. Assessing for disconnected tubing is essential, but if the cause of the high-pressure alarm is unclear and the client is in distress, manual ventilation should take precedence.
C. When a high-pressure alarm sounds on a mechanical ventilator and the cause is not immediately identifiable, the nurse should prioritize the client's safety by delivering breaths manually with a resuscitation bag. This ensures that the client continues to receive oxygen while troubleshooting the ventilator issue. Manual ventilation is crucial in preventing hypoxia during periods of mechanical failure or when the cause of the alarm cannot be quickly identified.
D. Decreasing the ventilator flow rate may not address the underlying issue causing the high-pressure alarm and could potentially worsen the situation. Immediate manual ventilation is the safest action.
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