The home health nurse visits a patient with multiple sclerosis who complains of severe fatigue. Select the nurse's best suggestion to help decrease their symptom of fatigue.

Relax in a hot bath before bedtime.

Perform deep breathing exercises every two hours.

Schedule short periods of rest throughout the day.

Include daily multivitamins in your diet.

Answer and Explanation

The Correct Answer is C

Choice A reason: Relaxing in a hot bath before bedtime is not the best suggestion to help decrease fatigue for a patient with multiple sclerosis. Heat can worsen the symptoms of multiple sclerosis, such as muscle weakness, numbness, and vision problems. Therefore, the patient should avoid hot baths, showers, or saunas, and use cool compresses or fans to lower their body temperature.

Choice B reason: Performing deep breathing exercises every two hours is not the best suggestion to help decrease fatigue for a patient with multiple sclerosis. Deep breathing can help reduce stress and anxiety, but it does not address the underlying causes of fatigue, such as inflammation, nerve damage, or sleep problems. Therefore, the patient should consult their doctor for appropriate treatment options and medication adjustments.

Choice C reason: Scheduling short periods of rest throughout the day is the best suggestion to help decrease fatigue for a patient with multiple sclerosis. Fatigue is a common and disabling symptom of multiple sclerosis, which can affect the patient's daily activities and quality of life. Therefore, the patient should plan their tasks according to their energy level, prioritize the most important ones, and take frequent breaks to conserve their energy and prevent exhaustion.

Choice D reason: Including daily multivitamins in your diet is not the best suggestion to help decrease fatigue for a patient with multiple sclerosis. Multivitamins can provide some nutritional benefits, but they are not a substitute for a balanced and healthy diet. Therefore, the patient should eat a variety of foods, such as fruits, vegetables, whole grains, lean proteins, and low-fat dairy, and avoid processed, fried, or sugary foods that can increase inflammation and fatigue.

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Correct Answer is A

Explanation

Choice A reason: Decreased hematocrit and hemoglobin indicate anemia, which is a condition where the blood does not carry enough oxygen to the tissues. This can cause symptoms such as confusion, restlessness, fatigue, and weakness in older adults.

Choice B reason: Increased erythrocyte count, or polycythemia, is a condition where the blood has too many red blood cells. This can cause the blood to become thick and viscous, which can impair blood flow and oxygen delivery. However, this is not the best explanation for the patient's confusion and restlessness, as polycythemia usually causes symptoms such as headache, dizziness, itching, and flushing.

Choice C reason: Normochromic red blood cells are red blood cells that have a normal color and hemoglobin content. This is not a finding that would explain the patient's confusion and restlessness, as it indicates a normal red blood cell function.

Choice D reason: Decreased thrombocytes, or platelets, are blood cells that help with clotting. This is a finding that would increase the risk of bleeding, but not the risk of confusion and restlessness. Decreased thrombocytes can cause symptoms such as bruising, bleeding gums, nosebleeds, and petechiae.

A. Maintain pressure to the puncture site and observe for drainage. B. Complete a pain assessment and administer an ordered analgesic, as needed. C. Inform the patient they may feel pressure and sharp pain in their lower back for several hours. D. Assess pulses distal to the lumbar puncture site every two hours.

Correct Answer is A

Explanation

Choice A reason: Maintaining pressure to the puncture site and observing for drainage is the priority nursing intervention for a patient who had a lumbar puncture. It helps to prevent bleeding, hematoma, and cerebrospinal fluid leakage, which can cause complications such as infection, headache, or nerve damage.

Choice B reason: Completing a pain assessment and administering an ordered analgesic, as needed, is an important nursing intervention for a patient who had a lumbar puncture, but it is not the priority. Lumbar puncture can cause mild to moderate pain and discomfort at the puncture site, which can be relieved by analgesics, ice packs, or massage.

Choice C reason: Informing the patient they may feel pressure and sharp pain in their lower back for several hours is an important nursing intervention for a patient who had a lumbar puncture, but it is not the priority. Lumbar puncture can cause transient sensations of pressure and pain in the lower back, which can be reduced by lying flat, avoiding sudden movements, and drinking fluids.

Choice D reason: Assessing pulses distal to the lumbar puncture site every two hours is not an appropriate nursing intervention for a patient who had a lumbar puncture. Lumbar puncture does not affect the blood circulation to the lower extremities, unless there is a complication such as hematoma or nerve compression. Therefore, the nurse should monitor the neurological status, vital signs, and signs of infection or bleeding.

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The home health nurse visits a patient with multiple sclerosis who complains of severe fatigue. Select the nurse's best suggestion to help decrease their symptom of fatigue.

Nursing Test Bank

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