The nurse is preparing for discharge a client with a history of celiac disease who now has developed multiple sclerosis. Which instruction is most important for the nurse to include in the discharge teaching plan?

Take prescribed cortisone accurately.<br>

Increase daily intake of sodium in diet.

Avoid extreme environmental temperatures.

Use a walker when weakness occurs

Answer and Explanation

The Correct Answer is C

Rationale

A. It's crucial for the client to adhere strictly to the prescribed dosage and schedule to maximize therapeutic benefits and minimize potential side effects. However, temperature regulation is priority

B. Celiac disease requires strict adherence to a gluten-free diet to prevent intestinal damage, while multiple sclerosis management may involve dietary strategies to manage symptoms like fatigue or bladder dysfunction. However, increasing sodium intake generally is not a primary concern unless there are specific indications related to multiple sclerosis symptoms or medication effects.

C. Temperature sensitivity is common in multiple sclerosis, and exposure to extreme heat or cold can exacerbate symptoms such as fatigue, weakness, and cognitive dysfunction. Managing environmental temperature exposure is crucial to minimizing symptom exacerbation and maintaining comfort and safety.

D. Mobility aids, such as walkers, can assist individuals with multiple sclerosis during periods of weakness or impaired balance. Using a walker appropriately can help prevent falls and promote safe mobility. However, this instruction may be more specific to managing symptoms of multiple sclerosis rather than addressing the complex dietary needs associated with celiac disease.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

A. Select foods that are lower in caloric density
Effective: Choosing foods that are lower in caloric density (such as fruits, vegetables, lean proteins) can help the client feel fuller with fewer calories. This can support weight maintenance or even weight loss if that is the goal.

B. Increase exercise intensity
Effective: Increasing exercise intensity can help the client burn more calories, contributing to energy expenditure. This can assist in achieving energy balance, particularly if the client wants to maintain her current weight while consuming adequate calories.

C. Get up and walk at least once an hour at work
Effective: Incorporating regular physical activity throughout the day, such as walking breaks, helps increase energy expenditure. It also breaks up sedentary behavior, which is beneficial for overall health and can contribute to energy balance.

D. Add healthy foods to increase caloric intake
Ineffective: Adding healthy foods to increase caloric intake would likely lead to a positive energy balance (where intake exceeds expenditure), potentially causing weight gain. Since the goal is to maintain weight, increasing caloric intake, even with healthy foods, would not be effective.

E. Avoid food with high carbohydrate levels
Ineffective: Carbohydrates are an important source of energy. Avoiding foods with high carbohydrate levels could limit the client's energy intake, potentially leading to negative energy balance if not replaced adequately with other nutrients.

A. Assess for symmetrical chest movement.<br> B. Auscultate for presence of bilateral breath sounds. C. Obtain a portable chest x-ray to verify ETT location. D. Monitor ETT markings between 22 and 26 cm at teeth line. E. Check for capillary refill of 3 seconds or less.

Correct Answer is ["A","B","C"]

Explanation

Rationale

A. This involves visually inspecting the chest to ensure both sides rise and fall equally during ventilation. Symmetrical chest movement suggests that both lungs are being adequately ventilated.

B. Auscultation involves listening with a stethoscope over the chest to confirm the presence of breath sounds in both lung fields. Bilateral breath sounds indicate that the ETT is correctly positioned in the trachea, allowing air to reach both lungs.

C. A chest x-ray provides a definitive confirmation of the ETT placement in relation to the trachea and lungs. It allows visualization of the tube's position relative to anatomical landmarks, such as the carina, which helps ensure proper placement.

This involves checking the markings on the ETT tube to ensure it is inserted to the correct depth. Typically, the ETT should be positioned with its tip approximately 2 to 4 cm above the carina, which corresponds to the 22-26 cm mark at the teeth line in adults. However, it does not confirm correct placement.

E. Capillary refill is a measure of peripheral perfusion and is unrelated to ETT placement. It assesses circulatory status by pressing on a nail bed and observing the time it takes for color to return. It does not provide information about ETT placement.

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The nurse is preparing for discharge a client with a history of celiac disease who now has developed multiple sclerosis. Which instruction is most important for the nurse to include in the discharge teaching plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse discusses the keep to balance energy intake and output to maintain weight Click to indicate whether the following actions would be effective or ineffective for this client to achieve energy balance. Each row must have one option selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

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