The nurse is caring for a client with multiple sclerosis. What actions does the nurse implement to increase venous return, prevent stiffness, and maintain muscle strength and endurance?

Administer corticosteroids

Turn and reposition every 2 hours

Administer interferon

Encourage range-of-motion exercises

Answer and Explanation

The Correct Answer is D

Choice A reason: Administering corticosteroids is not an action that the nurse implements to increase venous return, prevent stiffness, and maintain muscle strength and endurance because it is a medication that reduces inflammation and relieves acute exacerbations of multiple sclerosis, but does not affect the client's physical function or mobility.

Choice B reason: Turning and repositioning every 2 hours is not an action that the nurse implements to increase venous return, prevent stiffness, and maintain muscle strength and endurance because it is a nursing intervention that prevents pressure ulcers and promotes skin integrity, but does not enhance the client's circulation or muscle activity.

Choice C reason: Administering interferon is not an action that the nurse implements to increase venous return, prevent stiffness, and maintain muscle strength and endurance because it is a medication that modifies the immune system and delays the progression of multiple sclerosis, but does not improve the client's physical function or mobility.

Choice D reason: Encouraging range-of-motion exercises is an action that the nurse implements to increase venous return, prevent stiffness, and maintain muscle strength and endurance because it is a physical activity that improves the client's blood flow, flexibility, and muscle tone, as well as prevents contractures and spasticity.

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Correct Answer is A

Explanation

Choice A reason: "Move objects away from the client." This instruction should be included in the teaching because it can prevent injury and protect the client from harm during a seizurE.

Choice B reason: "Restrain the client." This instruction should not be included in the teaching because it can cause injury and increase agitation and anxiety for the client during a seizurE.

Choice C reason: "Place the client on his back." This instruction should not be included in the teaching because it can increase the risk of aspiration and airway obstruction for the client during a seizurE.

Choice D reason: "Insert a padded tongue blade into the client's moutH." This instruction should not be included in the teaching because it can cause injury and choking for the client during a seizurE.

A. The child looks at the floor when answering the nurse's quesons. B. The mother describes in detail what she did for her injured child. C. The abrasions on the child's arms, legs, and chest have healed. D. The injury descripon by the mother varies from the child's version.

Correct Answer is D

Explanation

- Child abuse is the intentional or neglectful physical, emotional, or sexual harm or injury of a child by a parent, caregiver, or another person who has a relationship of trust or responsibility with the child. Child abuse can have serious and long-lasting consequences for the child's health, development, and well-being.

- The practical nurse (PN) has a legal and ethical duty to identify, report, and prevent child abuse. The PN should be alert for any signs and symptoms of child abuse, such as unexplained or inconsistent injuries, bruises, burns, fractures, or scars; behavioural changes, such as fear, anxiety, aggression, withdrawal, or depression; poor hygiene, nutrition, or growth; lack of supervision, medical care, or education; or sexualized behaviours or knowledge.

- The PN should also conduct a thorough and sensitive assessment of the child and the family situation, using open-ended questions, active listening, and a non-judgmental attitude. The PN should compare the history and physical findings of the child with the expected developmental milestones and normal variations for the child's age and stage. The PN should also document any relevant information in an objective and factual manner.

- When the mother of a school-aged boy tells the PN that he fell out of a tree and hurt his arm and shoulder, the PN should assess the child's injury and compare it with the mother's explanation. The most significant indicator of possible child abuse in this scenario is if the injury description by the mother varies from the child's version. This may suggest that the mother is lying or covering up the true cause of the injury, which may be intentional or accidental harm by herself or someone else. A discrepancy between the mother's and the child's stories may also indicate that the child is afraid or coerced to hide the truth about the abuse.

- Therefore, option D is the correct answer, while options A, B, and C are incorrect.

- Option A is incorrect because the child looking at the floor when answering the nurse's questions may not be a sign of abuse, but rather a sign of shyness, embarrassment, pain, or discomfort.

Option B is incorrect because the mother describing in detail what she did for her injured child may not be a sign of abuse, but rather a sign of concern, care, or guilt.

Option C is incorrect because the abrasions on the child's arms, legs, and chest having healed may not be a sign of abuse, but rather a sign of normal wound healing or previous accidents.

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The nurse is caring for a client with multiple sclerosis. What actions does the nurse implement to increase venous return, prevent stiffness, and maintain muscle strength and endurance?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizurE. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

The mother of a school-aged boy tells the praccal nurse (PN) that he fell out of a tree and hurt his arm and shoulder. Which assessment should the praccal nurse (PN) note as the most significant indicator of possible child abuse?

Correct Answer is D

Explanation

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