Which outcome would the nurse include in the care plan for a patient with multiple sclerosis (MS)? Select all that apply.
Make decisions about health and lifestyle modifications to manage MS
Cure the disease
Maintain or improve muscle strength and mobility
Maintain urinary continence
Maintain independence in performing ADLs
Correct Answer : A,C,D,E
Choice A reason: The nurse would include making decisions about health and lifestyle modifications to manage MS because this helps the patient to make informed choices that can alleviate symptoms and improve their quality of life. Modifying aspects such as diet, exercise, and stress management can play a significant role in managing the disease and preventing relapses.
Choice B reason: Curing the disease is not currently a feasible outcome for multiple sclerosis, as there is no known cure. The focus of the care plan is typically on managing symptoms, slowing the progression of the disease, and improving the patient's quality of life rather than curing the disease.
Choice C reason: Maintaining or improving muscle strength and mobility is crucial for patients with MS, as the disease often affects muscle control and strength. Including this outcome in the care plan helps to reduce the risk of falls, improve the patient's ability to perform daily tasks, and enhance overall physical function.
Choice D reason: Maintaining urinary continence is an important aspect of care for MS patients, as the disease can affect bladder control. Including this outcome helps to ensure the patient's comfort and dignity, prevent urinary tract infections, and improve their quality of life.
Choice E reason: Maintaining independence in performing activities of daily living (ADLs) is essential for patients with MS to ensure they can continue to perform tasks such as bathing, dressing, and eating. This outcome supports the patient's self-esteem and promotes a sense of autonomy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: 0.45% sodium chloride is a hypotonic solution, which is not ideal for rapidly replacing fluid volume in patients with low blood pressure due to severe diarrhea. Hypotonic solutions can cause fluid to move into cells rather than staying in the vascular space, potentially worsening hypotension.
Choice B reason: 0.9% sodium chloride, also known as normal saline, is an isotonic solution. It is the best choice for rapidly replacing fluid volume in patients with low blood pressure. Isotonic solutions stay in the vascular space and help restore circulating blood volume and blood pressure without causing fluid shifts that can lead to cellular edema or dehydration.
Choice C reason: 5% dextrose in 0.9% sodium chloride is a hypertonic solution, which might not be the most appropriate for initial rapid fluid resuscitation. Hypertonic solutions can draw fluid into the vascular space from the interstitial and intracellular spaces, potentially leading to rapid changes in fluid balance and electrolyte shifts.
Choice D reason: 5% dextrose in 0.45% sodium chloride is also a hypertonic solution but with a hypotonic component (0.45% sodium chloride). This combination is not typically used for rapid fluid resuscitation because it can cause fluid shifts that are less predictable and may complicate the patient's electrolyte balance and hydration status.
Correct Answer is D
Explanation
Choice A reason: The nurse assistant typically performs tasks such as patient hygiene, ambulation, and basic monitoring under the supervision of registered nurses. They are not usually responsible for documenting vital signs during the intra-operative period.
Choice B reason: The anesthesiologist is primarily focused on managing the patient's anesthesia and monitoring their physiological status during surgery. While they do keep track of vital signs, the formal documentation is typically the responsibility of the circulating nurse.
Choice C reason: The scrub nurse is focused on maintaining the sterile field, handling surgical instruments, and assisting the surgeon. They do not leave the sterile field to document vital signs.
Choice D reason: The circulating nurse is responsible for overall patient care in the operating room, including documentation of vital signs. They manage the operating room environment, ensure patient safety, and record all necessary information during the intra-operative period.
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