The nurse provides 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 should alternate the eye patch every other day to help with the double vision."
"I may experience visual disturbances."
"I need to check the water temperature before I take a bath."
Correct Answer : B,C
Choice A reason: "I may experience urinary incontinence." This statement does not indicate the need for additional teaching. It is a correct statement that reflects an understanding of one of the possible symptoms of MS. Urinary incontinence is caused by nerve damage that affects bladder control.
Choice B reason: "I should not exercise because this may trigger an exacerbation." This statement indicates the need for additional teaching. It is an incorrect statement that reflects a misconception about exercise and MS. Exercise does not cause or worsen MS relapses but rather has many benefits for people with MS, such as improving muscle strength, balance, mobility, mood, and quality of life.
Choice C reason: "I should alternate the eye patch every other day to help with the double vision." This statement indicates the need for additional teaching. It is an incorrect statement that reflects a misunderstanding of how to manage double vision, which is another possible symptom of MS. Alternating the eye patch every other day does not help with double vision, but rather may cause eye fatigue or confusion. The correct way to use an eye patch is to wear it on one eye only when needed, such as when reading or driving.
Choice D reason: "I may experience visual disturbances." This statement does not indicate the need for additional teaching. It is a correct statement that reflects an awareness of another possible symptom of MS. Visual disturbances may include blurred vision, loss of color vision, pain in one eye, or partial or complete blindness.
Choice E reason: "I need to check the water temperature before I take a bath." This statement does not indicate the need for additional teaching. It is a correct statement that reflects a precaution that people with MS should take. Checking the water temperature before taking a bath can prevent burns or scalds, as some people with MS may have reduced sensation or numbness in their skin.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Developing a survey on teen pregnancies is not a priority intervention for a public health nurse who is assigned to a new community. This is a specific topic that may not be relevant or important for the whole population. A survey also requires time and resources to design, distribute, and analyze.
Choice B reason: Holding a focus group to discuss immunizations is not a priority intervention for a public health nurse who is assigned to a new community. This is a specific topic that may not be representative of the community's health needs and concerns. A focus group also requires recruitment, facilitation, and interpretation of the participants' views.
Choice C reason: Interviewing the elderly at the senior center is not a priority intervention for a public health nurse who is assigned to a new community. This is a specific group that may not reflect the diversity and characteristics of the whole population. An interview also requires consent, rapport, and recording of the responses.
Choice D reason: Performing a windshield survey is a priority intervention for a public health nurse who is assigned to a new community. This is a general method that allows the nurse to observe and assess various aspects of the environment that affect the health and well-being of the population. A windshield survey also requires minimal resources and can be done quickly and easily. A windshield survey is a method of assessing the health needs and resources of a community by driving or walking around and observing various aspects of the environment, such as housing, transportation, services, and safety. This is a priority intervention for a public health nurse who wants to get a comprehensive overview of the community and identify its strengths and weaknesses.
Correct Answer is A
Explanation
Choice A reason: It is a tool that is used to determine your maximum level of self-sufficiency as the appropriate nursing response, as it accurately describes the purpose and function of the FIM. The FIM measures how much assistance you need to perform 18 activities of daily living, such as eating, dressing, toileting, walking, and communicating. The FIM helps to evaluate your functional status, monitor your progress, and plan your rehabilitation goals and interventions. ¹²³
Choice B reason: It is a test that determines which activities you feel most comfortable performing is not an appropriate nursing response, as it does not reflect the objective and standardized nature of the FIM. The FIM is not a subjective or self-reported measure of your preferences or comfort level, but rather an observational and rating scale that assesses your actual performance and independence in various tasks. The FIM uses a 7-point ordinal scale that ranges from 1 (total assistance) to 7 (complete independence) and requires trained and certified raters to administer and score it. ¹²³
Choice C reason: It is a tool used by insurance companies to determine qualifications for medical reimbursement is not an appropriate nursing response, as it does not capture the primary purpose and benefit of the FIM. The FIM is not a financial or administrative tool that determines your eligibility or coverage for medical services, but rather a clinical and research tool that measures your functional outcomes and quality of care. The FIM provides a uniform system of measurement for disability based on the International Classification of Impairment, Disabilities, and Handicaps and allows for comparison and evaluation of different rehabilitation programs and settings. ¹²³
Choice D reason: It is a tool that is used to assess what services you will need a home health aide to perform for you is not an appropriate nursing response, as it does not reflect the comprehensive and multidimensional scope of the FIM. The FIM is not a specific or limited tool that assesses only your home care needs or dependence on others, but rather a general and broad tool that assesses your functional abilities and disabilities in various domains and environments. The FIM covers both motor and cognitive aspects of functioning, such as comprehension, expression, social interaction, problem-solving, and memory. The FIM can be used with all diagnoses within rehabilitation and can be applied across different levels and settings of care.
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