The nurse is caring for a client diagnosed with multiple sclerosis (MS) who is complaining of diplopia. Which intervention would be appropriate for the client with this problem?

Assess for conjunctival bleeding

Encourage the use of sunglasses when outside

Alternate the use of an eye patch on each eye

Apply cool compresses for pain relief

This result is consistent with partially compensated respiratory alkalosis. In respiratory alkalosis, the pH would be elevated (alkalotic), PaCO2 would be low (indicating hyperventilation), and the kidneys would attempt to compensate by lowering bicarbonate (HCO3). In this case, the low PaCO2 (23 mmHg) and the low HCO3 (14 mEq/L) demonstrate partial compensation. The pH is also elevated at 7.64, which aligns with alkalosis. This is the correct answer for partially compensated respiratory alkalosis.

Answer and Explanation

The Correct Answer is C

A) Assess for conjunctival bleeding
Conjunctival bleeding refers to blood in the white part of the eye (the conjunctiva), which is typically associated with trauma, infections, or certain blood disorders, but it is not a common cause of diplopia (double vision). Diplopia in multiple sclerosis (MS) is more often due to nerve damage affecting the eye muscles or the pathways controlling eye movement. Therefore, assessing for conjunctival bleeding is not a priority intervention for a client with diplopia related to MS.

B) Encourage the use of sunglasses when outside
While wearing sunglasses may help alleviate light sensitivity, which is a common symptom in individuals with MS, it is not the most appropriate intervention for treating diplopia itself. Diplopia is typically caused by issues with eye muscle control or coordination, often related to the central nervous system. Therefore, while sunglasses might provide comfort, they do not address the underlying cause of the double vision.

C) Alternate the use of an eye patch on each eye
Alternating the use of an eye patch on each eye is an effective intervention for managing diplopia, especially when the cause is related to misalignment or weakness of the eye muscles. The eye patch works by covering one eye at a time to prevent double vision. In MS, this technique can help reduce the visual disturbance and provide relief until further interventions (such as eye exercises or medications) can be considered. This approach is commonly used to manage diplopia caused by nerve involvement affecting ocular muscle function.

D) Apply cool compresses for pain relief
Cool compresses may provide relief for eye irritation or inflammation, but they are not typically used to treat diplopia. Diplopia in MS is more related to neuromuscular dysfunction or nerve damage, rather than acute inflammation or irritation of the eye. Therefore, while a cool compress may offer temporary relief for other symptoms, it is not a targeted solution for double vision in this context.

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Correct Answer is D

Explanation

A. Schedule activities late in the day and in the evening:

Scheduling activities late in the day is not an ideal approach for managing fatigue in clients with MS. Fatigue typically worsens as the day progresses, and clients with MS often experience more energy depletion in the late afternoon and evening. Therefore, the best time to schedule demanding activities is earlier in the day when the client may have more energy. Scheduling strenuous tasks late in the day may exacerbate fatigue and lead to physical and emotional exhaustion.

B. Provide supplemental oxygen when fatigued:

While oxygen therapy is appropriate for clients with respiratory issues or other conditions that affect oxygenation, it is not the most relevant intervention for addressing fatigue in MS. Fatigue in MS is primarily caused by neurological factors, muscle weakness, or impaired mobility, not by a lack of oxygen. The priority for MS-related fatigue is managing energy levels through activity planning and rest, not providing supplemental oxygen unless there is a specific indication of respiratory distress or hypoxia.

C. Teach the importance of hot showers to help relax:

Hot showers may help some individuals relax, but they are not the best intervention for managing fatigue in MS. In fact, heat can sometimes worsen symptoms in clients with MS, a phenomenon known as Uhthoff’s phenomenon, where heat increases neurological symptoms such as muscle weakness, fatigue, or visual disturbances. It is important to educate clients to avoid overheating, which could exacerbate fatigue or other symptoms. Instead, clients should focus on rest, energy conservation, and temperature regulation.

D. Have the client prioritize activities for the day: Fatigue is a common and debilitating symptom in clients with multiple sclerosis (MS), and it can significantly affect their daily functioning. One of the most effective interventions for managing fatigue in MS is to encourage the client to prioritize activities and manage their energy levels throughout the day. By scheduling the most important or demanding tasks earlier in the day when energy levels tend to be higher, clients can conserve energy for essential activities. Additionally, teaching clients to break tasks into smaller, manageable steps and incorporating frequent rest periods can help minimize fatigue and prevent overexertion. Prioritizing activities ensures that the client is not overwhelmed and can still maintain independence while managing their symptoms effectively.

A. decrease in heart rate. B. relief of chest pain. C. decrease in cardiac dysrhythmias. D. decrease in blood pressure.

Correct Answer is B

Explanation

A. Decrease in heart rate: While nitroglycerin can sometimes cause reflex tachycardia (an increase in heart rate) as a compensatory mechanism in response to a decrease in blood pressure, its primary effect is on reducing myocardial oxygen demand through vasodilation. Although heart rate may decrease in some situations due to improved perfusion or as a secondary response to pain relief, a decrease in heart rate is not the most reliable or immediate indicator of effectiveness in this context. The relief of chest pain is a more direct measure of the drug's impact.

B. Relief of chest pain: Nitroglycerin works by dilating blood vessels, which reduces myocardial oxygen demand and improves blood flow to the heart, particularly in cases of acute myocardial infarction (MI). The primary therapeutic goal is to relieve chest pain (angina) and reduce the workload of the heart. Monitoring for relief of chest pain is the most direct and important indicator of the medication's effectiveness. If the chest pain decreases or resolves, it suggests that the medication is helping to alleviate the ischemia caused by the MI.

C. Decrease in cardiac dysrhythmias: Nitroglycerin is not primarily used to treat dysrhythmias, although improved perfusion and reduced myocardial oxygen demand may indirectly reduce the occurrence of dysrhythmias in some cases. However, a decrease in dysrhythmias is not a primary goal of nitroglycerin therapy, and the nurse should not primarily monitor for this outcome. Any dysrhythmias should be managed with other specific interventions if needed.

D. Decrease in blood pressure: Nitroglycerin's vasodilatory effect does lead to a reduction in blood pressure, particularly in patients with high blood pressure or in the context of a myocardial infarction. However, excessive hypotension can be dangerous and may lead to inadequate perfusion of vital organs. The nurse must monitor blood pressure closely to avoid hypotension, but a decrease in blood pressure is not the main goal of therapy. The primary objective is to relieve the chest pain associated with the MI. If blood pressure drops too low, it may indicate a need to adjust the dose or discontinue the nitroglycerin.

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The nurse is caring for a client diagnosed with multiple sclerosis (MS) who is complaining of diplopia. Which intervention would be appropriate for the client with this problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client diagnosed with multiple sclerosis (MS) is at risk for fatigue. Which priority intervention would the nurse implement to address this issue?

Correct Answer is D

Explanation

The nurse administers IV nitroglycerin to a client diagnosed with an acute myocardial infarction. In evaluating the effectiveness of this intervention, the nurse should monitor for:

Correct Answer is B

Explanation

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