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 ["B","E"]

Explanation

Choice A reason: Elevating the buttocks with a pillow is not specifically indicated in the scenario provided. While it might assist in other situations to reduce swelling by using gravity, it isn't a standard intervention for the described situation post-TURP.

Choice B reason: Applying a cold pack to the scrotal and penile areas can help reduce the swelling and discomfort associated with edema. Cold therapy is effective in constricting blood vessels and reducing inflammation, making it an appropriate immediate intervention.

Choice C reason: While obtaining a urinalysis might provide information on the presence of infection or other abnormalities, it does not directly address the immediate issue of the observed edema. Therefore, it is not a primary intervention in this scenario.

Choice D reason: Removing the indwelling urinary catheter without specific orders can lead to complications and is not advised as an initial intervention. The catheter serves a critical purpose post-surgery and should be handled according to protocol or provider direction.

Choice E reason: Notifying the healthcare provider immediately is crucial when unexpected postoperative complications such as edema occur. Prompt communication allows for timely medical intervention and ensures that the patient receives the necessary care.

A. Check the client's current fingerstick blood glucose. B. Obtain blood pressure and heart rate. C. Administer a PRN dose of regular insulin. D. Give the client 4 ounces (120 mL) of orange juice. E. Provide the client with 1/2 cup (120 mL) diet carbonated soda.

Correct Answer is ["A","D"]

Explanation

Choice A reason: Checking the client's current fingerstick blood glucose is important to determine if the confusion and weakness are due to hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar).

Choice B reason: Obtaining blood pressure and heart rate is useful for a general assessment but is secondary to assessing blood glucose levels in this scenario.

Choice C reason: Administering a PRN dose of regular insulin is not appropriate without first determining the client's blood glucose level. If the client is hypoglycemic, insulin could worsen the condition.

Choice D reason: Giving the client 4 ounces (120 mL) of orange juice is a quick way to raise blood sugar levels if the client is hypoglycemic.

Choice E reason: Providing diet carbonated soda is not effective for treating hypoglycemia because it does not contain sugar to raise blood glucose levels.

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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.

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Naxlex Comprehensive Predictor Exams

When assessing a client who had a transurethral resection of the prostate (TURP) one day ago, the nurse observes that his scrotum and penis are edematous. Which intervention(s) should the nurse implement? Select all that apply.

Correct Answer is ["B","E"]

Explanation

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Correct Answer is ["A","D"]

Explanation

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