The nurse is completing the admission assessment of a client with multiple sclerosis (MS). Which finding(s) should be reported to the healthcare provider immediately? Select all that apply.

Tinnitus.

Tachycardia.

Tremors.

Paresthesia.

Fever.

Answer and Explanation

Correct Answer : B,E

Choice A reason: Tinnitus is not an immediate concern in the context of multiple sclerosis.

Choice B reason: Tachycardia should be reported immediately as it could indicate an underlying cardiovascular issue or autonomic dysfunction.

Choice C reason: Tremors are a common symptom of multiple sclerosis and do not require immediate reporting unless there is a significant change.

Choice D reason: Paresthesia is also a common symptom of multiple sclerosis and does not require immediate reporting unless there is a significant change.

Choice E reason: Fever should be reported immediately as it can indicate an infection, which can exacerbate multiple sclerosis symptoms.

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Correct Answer is D

Explanation

Choice A reason: Preparing the client for a CT scan is important for diagnostic purposes but is not the immediate priority in managing severe pain.

Choice B reason: Straining the urine for stones is important for confirming the presence of renal calculi but should be done after managing the acute pain.

Choice C reason: Obtaining a urine specimen for analysis is useful for diagnosing infection or other abnormalities but is secondary to pain management.

Choice D reason: Administering a prescribed opioid analgesic is the first priority to relieve the client's severe pain and provide comfort.

A. Assist the client to lie down and turn to the side. B. Recommend the use of supplemental liquid feedings. C. Demonstrate use of a tucked-chin position while eating. D. Encourage the use of assistive feeding devices.

Correct Answer is C

Explanation

Choice A reason: Assisting the client to lie down may increase the risk of aspiration.

Choice B reason: Supplemental liquid feedings may be considered but do not address the immediate issue.

Choice C reason: Demonstrating the tucked-chin position can help reduce the risk of aspiration by ensuring the airway is protected during swallowing.

Choice D reason: Assistive feeding devices may help but do not address the immediate issue of frequent coughing during meals.

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The nurse is completing the admission assessment of a client with multiple sclerosis (MS). Which finding(s) should be reported to the healthcare provider immediately? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with renal calculi is experiencing hematuria and reports severe flank pain. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

The home health nurse makes a home visit to a client with amyotrophic lateral sclerosis (ALS). The client is sitting upright while feeding themselves and coughs frequently during the meal. Which action should the nurse implement?

Correct Answer is C

Explanation

A client with pancreatitis reports severe epigastric pain, so the nurse administers a prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement?

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