The nurse is caring for a patient who is admitted with an exacerbation of multiple sclerosis (MS). The nurse completes the hospital's fall scale and determines that the patient is a high fall risk. What is the most effective intervention for the nurse to perform to prevent falls for this patient?
Pad the client's bed rails
Apply restraints
Set the bed alarm
Maintain strict bed rest
The Correct Answer is C
Rationale:
A. While padding bed rails can reduce injury if a fall occurs, it does not actively prevent the patient from attempting to get out of bed or losing balance. It is a passive safety measure, not a primary fall-prevention strategy.
B. Physical restraints are not recommended for fall prevention due to the risk of injury, immobility, and psychological harm. Restraints may actually increase fall risk if patients struggle against them, and their use is regulated and reserved for emergency situations only.
C. Bed or chair alarms alert staff immediately when a high fall-risk patient attempts to get up unassisted, allowing timely intervention to prevent falls. This is an active safety measure that is evidence-based for patients with impaired mobility, weakness, or poor coordination, as often seen in MS exacerbations. Alarms support early recognition of risk behaviors while promoting patient independence.
D. Prolonged bed rest is not recommended because it can lead to deconditioning, muscle weakness, and further mobility deficits, which may increase fall risk over time. MS patients benefit from supervised mobility and activity as tolerated, combined with safety measures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Cognitive impairment in Parkinson’s disease typically presents as memory deficits, executive dysfunction, or difficulty with problem-solving, not primarily as a flat affect or reduced speech. While cognitive changes can occur, the client’s symptoms reflect emotional and affective changes rather than cognition.
B. Anxiety may present as restlessness, excessive worry, or agitation, which differs from a flat affect, soft speech, and reduced emotional expression. The observed signs are not indicative of anxiety.
C. A flat facial expression (masked facies), soft speech (hypophonia), and reduced emotional expression are classic non-motor symptoms of depression in Parkinson’s disease. Depression is common in PD due to dopamine depletion in mesolimbic and mesocortical pathways, affecting mood and affect. Recognizing these subtle non-motor signs is critical, as depression significantly impacts quality of life and functional outcomes.
D. Bradyphrenia refers to slowed thought processes, manifesting as delayed responses and mental processing. Although it may coexist with PD depression, it does not specifically explain flat affect or soft speech. The client’s presentation is more indicative of affective rather than cognitive slowing.
Correct Answer is A
Explanation
Rationale:
A. Fatigue is one of the most common and disabling symptoms of MS. Heat intolerance is frequent because elevated body temperature slows nerve conduction in demyelinated neurons, increasing fatigue and other MS symptoms. Resting in a cool environment helps the patient conserve energy, prevent exacerbation of symptoms, and maintain functional independence. Incorporating scheduled rest periods is a cornerstone of fatigue management in MS.
B. Planned short naps (20–30 minutes) can improve energy levels and cognitive function in patients with MS. Forbidding naps can lead to increased daytime sleepiness, decreased alertness, and overall worsening of fatigue, which negatively affects quality of life. Fatigue management focuses on energy conservation, not restricting rest.
C. Heat exposure can temporarily worsen MS symptoms through Uhthoff’s phenomenon, including fatigue, blurred vision, weakness, and numbness. Hot baths or showers may increase core body temperature, leading to transient worsening of fatigue and other neurologic symptoms. Cool or lukewarm water is generally recommended instead.
D. Cyclobenzaprine is a centrally acting muscle relaxant used to relieve skeletal muscle spasms. It does not address fatigue in MS and can cause sedation, dizziness, or lethargy, which may actually worsen fatigue. Fatigue management in MS relies on energy conservation strategies, activity pacing, and environmental modifications, not pharmacologic muscle relaxants.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.