The nurse continues to care for the client.

A nurse on the inpatient mental health unit is planning care for the client.

For each potential provider's prescription, click to specify if the prescription is anticipated or contraindicated for the client.

Rationale

• Encourage rigorous physical exercise to enhance mobility: While exercise can improve function, rigorous or high-intensity activity may exacerbate fatigue or trigger worsening of symptoms in MS. Exercise should be tailored to the client’s tolerance and done under professional guidance rather than encouraged rigorously at home. Overexertion may increase relapse risk or cause injury.

• Instruct the client to remove throw rugs from their home: Removing throw rugs reduces the risk of falls in clients with multiple sclerosis, especially those who have had gait disturbances or lower extremity weakness. Fall prevention is a standard safety intervention in MS care. This addresses environmental hazards and promotes safe ambulation at home.

• Request a provider referral for physical therapy: Physical therapy supports mobility, balance, and strength in clients with MS. PT interventions can help manage spasticity and prevent functional decline. Referral is appropriate for clients who continue to experience daily muscle spasms and intermittent functional limitations.

• Teach the client about self-administering glatiramer acetate: Glatiramer acetate is a disease-modifying therapy for MS, and teaching self-administration promotes adherence, autonomy, and consistent treatment. Education regarding proper technique, injection site rotation, and monitoring for side effects is a standard nursing intervention in MS management.

• Encourage the use of a hot tub to decrease muscle spasms: Hot tubs can exacerbate heat sensitivity in MS, potentially worsening muscle weakness, fatigue, or neurological symptoms. Heat intolerance is common in MS, making hot tub use an inappropriate intervention without professional guidance. Safer spasticity management strategies include stretching, PT, or pharmacologic interventions.

Rationale for correct choices

• Heart sounds: The presence of S3 and S4 heart sounds may indicate right ventricular strain or acute heart failure, which can occur secondary to a massive pulmonary embolism. This finding aligns with increased cardiac workload due to impaired pulmonary circulation. Heart sounds are not typically altered in pneumonia or pneumothorax unless severe cardiac compromise occurs.

• Respiratory pattern: Tachypnea and labored breathing can occur in all three conditions. In pulmonary embolism, rapid breathing compensates for hypoxemia. In pneumonia, increased respiratory rate results from impaired gas exchange and inflammation. In pneumothorax, rapid breathing occurs due to decreased lung expansion and oxygenation.

• Temperature: Fever (38.9° C/102° F) suggests an infectious process, consistent with pneumonia. Pulmonary embolism and pneumothorax typically do not present with elevated temperature unless secondary infection or inflammatory response is present.

• Lung sounds: Bilateral crackles indicate fluid or exudate in the alveoli. In pneumonia, crackles result from consolidation and inflammation. In pulmonary embolism, crackles may reflect pulmonary infarction or edema from right-sided heart strain. Pneumothorax generally produces absent or decreased breath sounds rather than crackles, so crackles are less indicative.