A nurse is evaluating a client who received intermittent IV fluids. Which of the following findings indicates the client has a fluid overload?

Choice A reason: Avoiding physical exercise is not recommended for multiple sclerosis, as moderate activity like walking or stretching improves muscle strength, balance, and fatigue management. Complete avoidance leads to deconditioning, worsening mobility and fatigue, which are common in MS, making this instruction counterproductive to symptom management.
Choice B reason: Taking hot baths is not advised for multiple sclerosis, as heat can exacerbate symptoms like fatigue and muscle weakness due to temperature sensitivity (Uhthoff’s phenomenon). Cool or lukewarm baths are safer, supporting symptom control, making this instruction harmful and inappropriate for MS management.
Choice C reason: Performing daily stretching exercises improves flexibility, reduces spasticity, and enhances mobility in multiple sclerosis. Stretching strengthens muscles and prevents contractures, supporting functional independence. This aligns with evidence-based MS management to mitigate symptoms and improve quality of life, making it the correct instruction.
Choice D reason: Limiting fluid intake to reduce bladder irritation is inappropriate, as adequate hydration (2-3 L/day) prevents urinary tract infections, common in MS due to bladder dysfunction. Fluid restriction can worsen symptoms and dehydration, making this instruction incorrect for managing MS-related bladder issues effectively.

Choice A reason: Removing restraints immediately risks safety, as the client’s calm state may not be sustained. Restraints require gradual removal after ensuring sustained behavioral stability, per facility policy and safety standards. Frequent monitoring is needed to assess ongoing safety, making this action premature and potentially unsafe.
Choice B reason: Encouraging group therapy is inappropriate while the client remains in restraints, as it does not address the immediate need to evaluate their behavior for safe restraint removal. Therapy may be beneficial later, but ongoing monitoring is the priority to ensure safety and compliance with restraint protocols.
Choice C reason: Continuing to monitor the client every 15 minutes ensures safety while assessing sustained calm and cooperative behavior. This adheres to restraint protocols, which require frequent checks to evaluate the need for continued restraint, prevent complications, and plan for safe removal, making it the correct action.
Choice D reason: Administering a sedative to maintain calm behavior is inappropriate without a current medical order or ongoing aggression. Sedatives carry risks like oversedation or respiratory depression. Monitoring the client’s behavior is the priority to determine if restraints can be safely discontinued, making this action unnecessary and potentially harmful.