A nurse is teaching a client who has multiple sclerosis. Which of the following instructions should the nurse include in the teaching?

"Schedule rest periods during the day."

"Soak in a hot bath."

"Perform aerobic activities three times per week."

"Have your partner complete activities of daily living for you."

Answer and Explanation

The Correct Answer is A

Rationale:
A. "Schedule rest periods during the day.": Fatigue is a common symptom of multiple sclerosis. Scheduling rest periods helps conserve energy, prevent exacerbation of symptoms, and improve overall functioning without overtaxing the client.

B. "Soak in a hot bath.": Heat can worsen multiple sclerosis symptoms by temporarily increasing nerve conduction delays. Hot baths may trigger fatigue or weakness and are generally discouraged.

C. "Perform aerobic activities three times per week.": While gentle exercise is beneficial, intense aerobic activity can exacerbate fatigue and heat sensitivity in clients with multiple sclerosis. Exercise should be balanced with rest periods.

D. "Have your partner complete activities of daily living for you.": Encouraging total dependence can reduce independence and self-efficacy. Clients should perform activities within their capacity to maintain function while pacing themselves appropriately.

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Correct Answer is C

Explanation

Rationale:
A. Change the drainage tubing every 48 hr: Routine changing of drainage tubing is not recommended unless it becomes contaminated or occluded. Frequent manipulation increases the risk of infection and compromises the sterile system.

B. Irrigate the drain to maintain suction: Irrigating a closed wound drainage system can introduce pathogens and disrupt the vacuum, increasing the risk of infection. Closed systems are designed to maintain suction without routine irrigation.

C. Observe for drainage flow through the tubing: Monitoring the amount, color, and consistency of drainage is essential to assess wound healing and detect complications such as infection or hemorrhage. Observing flow ensures the system is functioning properly and provides critical data for clinical decisions.

D. Remove the drain if output from the drain increases: Increased output can indicate ongoing bleeding or infection and should be reported to the provider. Premature removal of the drain in this situation could lead to fluid accumulation, wound dehiscence, or infection.

A. Assess pressure points every 24 hr. B. Turn and reposition the client every 3 hr while in bed. C. Teach the client to shift his weight every 15 min while sitting. D. Place the client upright ona donut-shaped cushion.

Correct Answer is C

Explanation

Rationale:
A. Assess pressure points every 24 hr: Skin assessment should be performed at least every shift or more frequently in high-risk clients. Waiting 24 hours between assessments increases the risk of progression from erythema to ulceration due to unrelieved pressure.

B. Turn and reposition the client every 3 hr while in bed: Clients at risk for pressure injuries should be repositioned at least every 2 hours in bed to promote circulation and reduce tissue ischemia. Extending this interval to 3 hours is inadequate for prevention or healing.

C. Teach the client to shift his weight every 15 min while sitting: Teaching the client to perform weight shifts every 15 minutes reduces pressure on the ischial areas, promoting blood flow and preventing further skin breakdown. This intervention empowers self-care and is a key preventive strategy for wheelchair-bound clients.

D. Place the client upright on a donut-shaped cushion: Donut cushions can impair circulation around the pressure site by concentrating pressure on surrounding tissue, worsening ischemia and tissue damage. Pressure-redistribution cushions or gel pads are safer alternatives.

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A nurse is teaching a client who has multiple sclerosis. Which of the following instructions should the nurse include in the teaching?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a closed wound drainage system. Which of the following interventions should the nurse include in the plan care?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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