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

Encourage the use of sunglasses when outside.

Assess for conjunctival bleeding.

Alternate the use of an eye patch on each eye.

Apply cool compresses for pain relief

Answer and Explanation

The Correct Answer is C

A. Encourage the use of sunglasses when outside: Sunglasses are useful for reducing glare and light sensitivity, but they do not address the underlying cause of diplopia (double vision) in Multiple Sclerosis (MS). Diplopia is often due to neurological damage affecting the eye muscles or nerve pathways, not from light sensitivity.

B. Assess for conjunctival bleeding: Conjunctival bleeding (bleeding under the eye's clear surface) is not related to diplopia. Diplopia in MS is caused by problems with the nerves or muscles controlling eye movement, and assessing for conjunctival bleeding would not help in managing the double vision.

C. Alternate the use of an eye patch on each eye: Diplopia in MS is commonly caused by eye misalignment due to nerve damage. Using an eye patch on one eye at a time can temporarily help by blocking vision in one eye, allowing the brain to focus and alleviating the perception of double vision. Alternating the patch between eyes is a common strategy to manage diplopia while treating the underlying neurological issues.

D. Apply cool compresses for pain relief: Cool compresses might help with general eye discomfort, but they do not directly address diplopia. Diplopia due to MS is usually caused by muscle or nerve issues rather than discomfort that could be relieved by cool compresses.

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Correct Answer is B

Explanation

A. Encourage the patient to write questions on a white erase board: While writing on a whiteboard can be a helpful method of communication for some patients with ALS, it may not be effective as the disease progresses. In the later stages of ALS, patients often lose the ability to use their hands or arms, making writing impossible.

B. Use pre-arranged eye signals because eye muscles remain intact: In the later stages of ALS, most voluntary muscle function is lost, except for eye muscles. Using eye movements or pre-arranged eye signals (e.g., blinking or moving eyes up or down) is an effective way to communicate with patients who can no longer speak or write. The nurse can establish a system of eye signals to communicate with the patient.

C. Speak slow and repeat phrases due to cognitive decline: ALS typically does not cause cognitive decline. It primarily affects motor function. Speaking slowly and repeating phrases may be helpful if the patient is struggling with speech, but cognitive impairment is not a common symptom in ALS.

D. Have the patient squeeze the nurse's hand when intubated and on the ventilator: When a patient is intubated and on a ventilator, they may not be able to effectively squeeze the nurse's hand due to the presence of a tube in their airway. Additionally, the ability to use hand movements may be lost in advanced ALS, making this method of communication unreliable.

A. The client will be turned every 2 hours B. The client will need to be monitored every one-half hour C. Documentation of the event will include interventions attempted prior to initiating restraints D. The physician must be present at the time of the restraint episode

Correct Answer is C

Explanation

A. The client will be turned every 2 hours is a general nursing care practice for all immobile clients to prevent pressure injuries, but it is not specific to the protocol surrounding the use of restraints.

B. The client will need to be monitored every one-half hour is incorrect because clients in restraints must be monitored more frequently—typically every 15 minutes, depending on facility policy and client condition, to assess circulation, skin integrity, and psychological well-being.

C. Documentation of the event will include interventions attempted prior to initiating restraints is the correct answer. Before applying restraints, it is a legal and ethical requirement to document all less restrictive interventions that were attempted and found ineffective. This ensures that restraints are used only as a last resort and that the client's rights and safety are protected.

D. The physician must be present at the time of the restraint episode is incorrect. While a physician's order is required for restraint use, the physician does not need to be physically present at the time of application. However, the physician must conduct a face-to-face evaluation within a specific timeframe, usually within 1 hour of the restraint being applied, depending on regulatory guidelines.

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

Nursing Test Bank

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