A young woman with multiple sclerosis just received several immunizations in preparation for moving into a college dormitory. Two days later, she reports to the nurse that she is experiencing increasing fatigue and visual problems. Which teaching should the nurse provide?"

These are common side effects of the vaccines and will resolve in a few days.

Immunizations can trigger a relapse of the disease, so get plenty of extra rest.

These early signs of an infection may require medical treatment with antibiotics.

Plans to move into the dormitory need to be postponed for at least a semester.

Answer and Explanation

The Correct Answer is B

Rationale:
A. These are common side effects of the vaccines and will resolve in a few days: While mild fatigue or soreness may occur after immunizations, increasing fatigue and visual changes in a patient with multiple sclerosis may indicate a disease relapse rather than routine vaccine side effects. Dismissing these symptoms could delay necessary evaluation.

B. Immunizations can trigger a relapse of the disease, so get plenty of extra rest: In individuals with multiple sclerosis, immunologic stimulation from vaccines can occasionally precipitate a relapse or exacerbate neurological symptoms. The nurse should teach the client to monitor for worsening symptoms, rest, and promptly report changes to her healthcare provider.

C. These early signs of an infection may require medical treatment with antibiotics: The symptoms described—fatigue and visual problems—are more consistent with an MS relapse than an infection. Antibiotics are not indicated unless there is clear evidence of a bacterial infection.

D. Plans to move into the dormitory need to be postponed for at least a semester: Relapse symptoms do not automatically require delaying life plans such as moving. Management should focus on monitoring, rest, and prompt evaluation rather than long-term lifestyle changes without medical guidance.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:
A. Administer the client's routine daily aspirin: Aspirin affects platelet aggregation but does not provide adequate anticoagulation for treatment of an acute deep vein thrombosis. Concurrent use with heparin increases bleeding risk without improving therapeutic anticoagulation. Aspirin is not part of initial DVT management unless specifically prescribed.

B. Encourage a diet high in iron and ascorbic acid: Iron and vitamin C support erythropoiesis and iron absorption but have no role in treating venous thromboembolism. Nutritional support does not influence clot stabilization or prevention of embolization. Dietary changes are not a priority during acute anticoagulation.

C. Maintain the client on bedrest: Bedrest limits lower extremity movement and reduces the risk of thrombus dislodgement during the acute phase of deep vein thrombosis. Immobilization is commonly recommended until anticoagulation has achieved a therapeutic effect. This intervention reduces the risk of pulmonary embolism.

D. Encourage the client to dangle the legs frequently: Dangling the legs increases venous pressure and mechanical movement, which can promote clot migration. This activity may increase the risk of embolization during the acute phase. Early ambulation is considered only after stabilization and provider clearance.

A. Insert indwelling urinary catheter B. Assess family strengths and resources and willingness to help care for the client after discharge C. Perform range-of-motion exercises twice per day D. Apply graduated compression stockings or sequential compression devices (SCDs) as prescribed E. Have an oral suction device available F. Establish a nonverbal communication code system

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Rationale:

• Insert indwelling urinary catheter: Invasive procedures, including catheterization, should be avoided for at least 24 hours after fibrinolytic (Tenecteplase/tPA) administration due to the high risk of internal bleeding. If absolutely necessary, they should have been inserted before the medication was given.

• Assess family strengths and resources: Evaluating the family’s ability to assist with care is critical for discharge planning. Stroke patients often require support with ADLs and mobility, and early assessment promotes safer transitions and continuity of care.

• Perform range-of-motion exercises twice per day: To prevent contractures, joint stiffness, and muscle atrophy, passive and active range-of-motion exercises should be performed on affected limbs. Early mobility interventions reduce complications of immobility.

• Apply graduated compression stockings or SCDs: Stroke patients are at increased risk for deep vein thrombosis due to immobility. Compression devices or stockings facilitate venous return and help prevent thromboembolic events.

• Have an oral suction device available: Clients with dysphagia, decreased gag reflex, or impaired consciousness are at risk for aspiration. Having suction available ensures airway protection and prevents respiratory complications.

• Establish a nonverbal communication code system: Clients with aphasia or expressive communication deficits benefit from a nonverbal code system to express needs, which supports patient safety, reduces frustration, and facilitates care delivery.

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A young woman with multiple sclerosis just received several immunizations in preparation for moving into a college dormitory. Two days later, she reports to the nurse that she is experiencing increasing fatigue and visual problems. Which teaching should the nurse provide?"

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

For each assessment finding click to indicate whether these nursing interventions are appropriate or not appropriate. Each column must have at least one response option selected.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

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