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 A

Explanation

Choice A reason: A history of suicide attempts is crucial information when planning the care of a client using heroin because there is a high risk of further suicide attempts, especially in individuals with substance use disorders. The nurse must prioritize mental health safety and implement measures to monitor and support the client's psychological well-being to prevent any potential self-harm.

Choice B reason: While family history of schizophrenia is important, it is not immediately crucial to the plan of care for a client currently using heroin. This information is more relevant for long-term monitoring and psychiatric evaluation rather than immediate care planning.

Choice C reason: Undiagnosed social anxiety disorder (SAD) may contribute to substance use; however, it is not the most urgent concern in this scenario. The focus should be on immediate safety and stabilization, particularly addressing the high risk of suicide.

Choice D reason: Feelings of disorientation are significant but could be a result of heroin use. While important to assess, they are secondary to the immediate concern of preventing self-harm in a client with a history of suicide attempts.

A. Hold urine for at least 10 minutes to dilute bacteria. B. Empty the bladder before and after sexual intercourse. C. Drink large amounts of fluids before bedtime. D. Cleanse the perineal area in a circular motion after voiding.

Correct Answer is B

Explanation

Choice A reason: Holding urine for at least 10 minutes does not dilute bacteria and can actually increase the risk of infection.

Choice B reason: Emptying the bladder before and after sexual intercourse helps flush out bacteria that may have been introduced during intercourse, reducing the risk of UTI.

Choice C reason: Drinking large amounts of fluids before bedtime is not specific to preventing UTIs and may lead to nighttime urination, disrupting sleep.

Choice D reason: Cleansing the perineal area in a circular motion is not the recommended method. The recommended practice is to wipe from front to back to prevent the spread of bacteria from the rectal area to the urethra.

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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

During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

Correct Answer is A

Explanation

The nurse is teaching a female client about preventive measures for urinary tract infections (UTI). Which information should the nurse include?

Correct Answer is B

Explanation

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