The nurse is planning care for a client with MS who has difficulty with coordination and fine motor skills. Which nursing action best independence with ADLs?

Provide adaptive devices such as built-up utensils

Focus only on physical therapy for gross motor control

Encourage the family to perform all care

Restrict all self-care activities to conserve energy

Answer and Explanation

The Correct Answer is A

Rationale:

A. Adaptive equipment (e.g., utensils with enlarged handles, button hooks, or modified pens) compensates for impaired fine motor skills, allowing the client to perform activities of daily living (ADLs) independently. This approach promotes self-efficacy, autonomy, and dignity, which are essential for maintaining quality of life in MS. Occupational therapy often guides device selection to match specific deficits.

B. While physical therapy is important for balance, strength, and gross motor coordination, focusing exclusively on it does not address fine motor deficits needed for feeding, dressing, or writing. This approach neglects key aspects of independence in ADLs.

C. Performing all ADLs for the client reduces independence and self-esteem, fosters dependency, and may contribute to learned helplessness. Nursing interventions should aim to maximize patient participation rather than replacing the client’s efforts.

D. While pacing is important to manage fatigue in MS, completely restricting self-care prevents skill use and independence. The goal is to balance activity with rest and use adaptive strategies, not to eliminate self-care entirely.

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Correct Answer is D

Explanation

Rationale:

A. There is no evidence of airway obstruction, secretion retention, or respiratory compromise in the assessment findings. Although acetone breath is present, it is a metabolic odor from ketones, not an indication of airway compromise. This diagnosis does not address the most urgent physiologic risk.

B. While dry skin and poor turgor are noted, these are symptoms of dehydration, not acute skin breakdown. Skin integrity issues are a secondary concern, not the immediate priority.

C. Although acetone breath suggests ketone accumulation, there is no evidence of hypoxia, cyanosis, or respiratory distress. The client may have compensatory Kussmaul respirations (deep, rapid breathing) due to metabolic acidosis, but gas exchange is not the primary threat at this stage.

D. The client exhibits classic signs of severe dehydration: Polyuria, polydipsia, polyphagia – signs of uncontrolled hyperglycemia (likely diabetic ketoacidosis), Orthostatic hypotension – indicates decreased intravascular volume, Dry, warm skin with poor turgor – indicates fluid loss from the extracellular compartment

Fluid replacement is the highest priority intervention, as hypovolemia can lead to shock, organ hypoperfusion, and death. Immediate IV fluids (typically isotonic saline) are essential before insulin therapy, to restore circulation and correct electrolyte imbalances safely.

A. Rest in a cool room whenever possible B. Avoid taking naps during the day C. Take a hot bath twice per day D. Take cyclobenzaprine as needed

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.

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The nurse is planning care for a client with MS who has difficulty with coordination and fine motor skills. Which nursing action best independence with ADLs?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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