The nurse is providing education to a client who is newly diagnosed with Multiple Sclerosis (MS). Which client statements indicate the need for additional teaching? SELECT ALL THAT APPLY
“I may experience urinary incontinence.”
“I should not exercise because this may trigger an exacerbation.”
“I need to check the water temperature before I take a bath.”
“I may experience visual disturbances.”
“I should alternate the eye patch every other day to help with the double vision.”
Correct Answer : B,E
Choice A reason:
“I may experience urinary incontinence.” This statement is correct. Urinary incontinence is a common symptom of MS due to the disease’s impact on the nervous system. The client does not need additional teaching regarding this statement.
Choice B reason:
“I should not exercise because this may trigger an exacerbation.” This statement indicates a need for additional teaching. Regular exercise is beneficial for individuals with MS and can help improve strength, mobility, and overall well-being. The nurse should educate the client on safe and appropriate exercise routines.
Choice C reason:
“I need to check the water temperature before I take a bath.” This statement is correct. Clients with MS may have impaired sensation and are at risk for burns if the water is too hot. Checking the water temperature is a necessary precaution.
Choice D reason:
“I may experience visual disturbances.” This statement is correct. Visual disturbances, such as blurred vision or double vision, are common symptoms of MS. The client does not need additional teaching regarding this statement.
Choice E reason:
“I should alternate the eye patch every other day to help with the double vision.” This statement indicates a need for additional teaching. While using an eye patch can help manage double vision, it should be alternated more frequently, typically every few hours, to prevent strain on the covered eye.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A reason:
Assigning the client to a private room is not the priority action in this scenario. The focus should be on decontamination and preventing the spread of the unknown substance to others in the emergency department. Isolation measures can be considered after initial decontamination.
Choice B reason:
Removing the client and transport crew from the Emergency department is a priority action to prevent contamination of the area and exposure to other patients and staff. This step helps contain the potential hazard and ensures the safety of everyone in the department.
Choice C reason:
Contacting the decontamination team is essential for managing the situation. The decontamination team has the expertise and equipment to safely remove the unknown substance from the client and transport crew, reducing the risk of further exposure and contamination.
Choice D reason:
Calling the scene to identify the chemical can be helpful, but it is not the immediate priority. The focus should be on decontamination and ensuring the safety of the client and others. Identifying the chemical can be done concurrently or after initial decontamination efforts.
Choice E reason:
Immediately removing the saturated clothing from the client is a critical step in the decontamination process. Removing contaminated clothing helps reduce the client’s exposure to the substance and prevents further absorption through the skin.
Correct Answer is D
Explanation
Choice A reason:
Restricting visitors to a few hours in the afternoon to promote client rest can help reduce fatigue, but it does not directly address the need to conserve energy throughout the day. While managing visitor times can be part of an overall strategy, it is not the most effective way to conserve energy for essential activities.
Choice B reason:
Scheduling all activities within a small block of time to allow the client a longer, uninterrupted rest period may lead to fatigue and decreased performance. Concentrating activities in a short time frame can be overwhelming and counterproductive, especially for clients with limited energy reserves.
Choice C reason:
Scheduling toilet breaks before and after any other planned activity is practical for managing personal needs but does not specifically address energy conservation. While it ensures that the client is comfortable, it does not optimize the timing of energy-intensive activities.
Choice D reason:
Scheduling energy-intensive activities at the time of day when the client has higher energy levels is the best approach to conserve energy without compromising physical or mental health. This strategy takes advantage of the client’s natural energy peaks, allowing them to perform activities more effectively and with less fatigue. It helps balance activity and rest, promoting overall well-being.
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