The nurse is teaching a client with MS about preventing falls at home. Which instruction would the nurse include?
Take long, fast strides when ambulating
Use dim lighting to prevent eye strain
Remove clutter and throw rugs from walking areas
Avoid using canes or walkers
The Correct Answer is C
Rationale:
A. Clients with MS often have gait disturbances, weakness, or balance issues. Long or rapid strides increase the risk of tripping and falling. Safe ambulation requires small, deliberate steps and possibly the use of assistive devices, rather than encouraging faster movement.
B. Poor lighting increases fall risk because clients may misjudge distances or fail to see obstacles. MS patients benefit from bright, evenly distributed lighting to enhance visibility, particularly in hallways, stairs, and bathrooms. Dim lighting is unsafe.
C. Eliminating obstacles such as clutter, loose rugs, or cords reduces tripping hazards and is a primary fall-prevention strategy for clients with MS. Ensuring clear, wide pathways and secure flooring promotes safety and independence at home.
D. Assistive devices like canes, walkers, or gait belts provide stability and support, reducing fall risk. Advising a client to avoid them is unsafe and counterproductive. Proper training on device use and placement is essential for safe mobility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["125"]
Explanation
Step 1: Use the formula
Flow rate (mL/hr) = Total volume ÷ Time (hr)
Step 2: Insert known values
Flow rate = 1,000 ÷ 8
Flow rate = 125 mL/hr
Final Answer: 125 mL/hr
Correct Answer is A
Explanation
Rationale:
A. The priority in HHNS is fluid resuscitation, as severe hyperglycemia causes profound dehydration, hyperosmolarity, and electrolyte imbalances. Rapid IV fluid replacement helps restore circulating volume, improve perfusion, and reduce blood glucose concentration indirectly. Fluids are given before insulin to avoid rapid fluid shifts and hypotension. Correcting dehydration is life-saving and is always the first step in HHNS management.
B. While confusion and lethargy may indicate altered mental status, airway compromise is not typically the immediate priority in HHNS. Intubation is only required if the patient’s airway is at risk due to decreased consciousness or respiratory failure. Immediate fluid resuscitation and stabilization are higher priorities.
C. Insulin therapy is important in HHNS to reduce blood glucose, but starting insulin before fluid replacement can cause rapid shifts in osmolarity, potentially leading to cerebral edema or cardiovascular collapse. Fluids must be administered first, and insulin is usually started after initial hydration.
D. Dextrose is used to treat hypoglycemia, not severe hyperglycemia. In HHNS, blood glucose is extremely high (925 mg/dL), so administering dextrose would worsen hyperosmolarity and exacerbate the patient’s condition. This intervention is completely inappropriate in this scenario.
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