The nurse is admitting a client with an exacerbation of multiple sclerosis. The client states, "I have been in remission for years and cannot imagine what might have caused this." Which question would be the best one to ask in trying to determine the cause of the relapse?

"Have you been under any emotional and physical stress lately?"

"Have you recently received the influenza vaccine?"

"Have you added any grapefruit juice to your diet lately?"

"Have you been out of the country in the past couple of months?"

Answer and Explanation

The Correct Answer is A

A. Exacerbations of multiple sclerosis (MS) are often triggered by stress, infection, fatigue, or extreme temperatures. Asking about emotional and physical stress is the most appropriate way to explore a likely cause for the relapse.
B. The influenza vaccine does not cause MS exacerbations and is generally recommended to help prevent infections, which can actually trigger relapses.
C. Grapefruit juice can interact with some medications, but it is not associated with MS exacerbations.
D. Travel history may be important for infectious disease screening but is not directly related to MS relapse triggers.

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Correct Answer is ["A","C","F","G","H","L"]

Explanation

A. Warm blankets provide external rewarming.
B. The room should be kept warm, not decreased.
C. Warm IV fluids prevent further heat loss and aid internal rewarming.
D. Acetaminophen is for fever reduction, not for hypothermia management.
E. A fan would worsen heat loss.
F. Warmed, humidified oxygen prevents further cooling and helps raise core body temperature.
G. Cardiac monitoring is essential since hypothermia increases the risk for arrhythmias.
H. A radiant warmer provides effective external rewarming.
I. Monitoring core temperature ensures safe and effective rewarming.

A. Call the health care provider immediately to assess the eye B. Apply direct pressure to the affected eye C. Generously flush the affected eye with normal saline. D. Generously flush the affected eye with an antibiotic solution.

Correct Answer is C

Explanation

A. While notifying the healthcare provider is important, it is not the priority. Immediate action is required to limit damage to the eye before permanent injury occurs.
B. Applying direct pressure to a chemical burn is contraindicated. It may worsen tissue injury and increase pain.
C. The priority action is to generously flush the affected eye with normal saline (or any available clean water if saline is not accessible) to dilute and remove the chemical as quickly as possible. Immediate irrigation can significantly reduce further damage to ocular tissues.
D. Antibiotic solution may be prescribed later to prevent infection, but it is not the immediate priority in the emergency phase. The first action must always be copious irrigation to neutralize and remove the chemical agent.

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Creatinine 1.8 mg/dL	Ref: 0.6-1.3 mg/dL
White blood cell (WBC) 16,000 mm3	Ref: 5,000-10,000 mm3
Platelet count 120,000	Ref: 140,000-400,000
C-Reactive Protein 5 mg/dL	Ref: <1 mg/dL

The nurse is admitting a client with an exacerbation of multiple sclerosis. The client states, "I have been in remission for years and cannot imagine what might have caused this." Which question would be the best one to ask in trying to determine the cause of the relapse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client with hypothermia who is on a ventilator and notes a temperature of 82.5°F (32.2°C). Drag from the list of possible interventions from the left to the right that are the most appropriate for the nurse to implement.

Correct Answer is ["A","C","F","G","H","L"]

Explanation

The nurse is caring for a client who was admitted to the emergency department after receiving a chemical burn to the eye. What is the priority nursing action for this client?

Correct Answer is C

Explanation

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The nurse is preparing discharge instructions for the family of a newborn. What will the nurse include in educating the parents about body temperature regulation? (Select all that apply)

The emergency department nurse has several clients present to triage with eye complaints. Which client will the nurse assess first?

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