Nokea
A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which statement should the nurse include in this client's discharge teaching?
- A. Take warm baths to promote muscle relaxation.
- B. Avoid people with upper respiratory illnesses.
- C. Relying on a walker will weaken your gait.
- D. Take prescribed medication only when symptoms occur.
Correct Answer: B
Rationale: Clients taking cyclophosphamide and methylprednisolone are immunocompromised and should avoid people with upper respiratory illnesses to prevent infections. Warm baths may help but are not the priority, relying on a walker does not necessarily weaken gait, and medications should be taken as prescribed, not only when symptoms occur.
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A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which instruction should the nurse include in this education?
- A. Participate in an exercise program to strengthen muscles.
- B. Purchase a mattress that allows you to adjust the firmness.
- C. Wear flat instead of high-heeled shoes to work each day.
- D. Keep your weight within 20% of your ideal body weight.
Correct Answer: A
Rationale: Exercise can strengthen back muscles, reducing the incidence of low back pain. The other options will not prevent low back pain.
A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod (Gilenya). For which adverse effect should the nurse monitor?
- A. Peripheral edema
- B. Black and tarry stools
- C. Bradycardia
- D. Nausea and vomiting
Correct Answer: C
Rationale: Fingolimod (Gilenya) can cause bradycardia, especially within the first 6 hours after administration. Peripheral edema, black and tarry stools, and nausea and vomiting are not typical adverse effects of this medication.
A nurse cares for a client with a lower motor neuron injury who is experiencing a flaccid bowel elimination pattern. Which actions should the nurse take to assist in relieving this client's complication? (Select all that apply.)
- A. Pour warm water over the perineum.
- B. Provide a diet high in fluids and fiber.
- C. Administer daily tap water enemas.
- D. Massage the abdomen from left to right.
- E. Perform manual disimpaction.
Correct Answer: B,D,F
Rationale: For a flaccid bowel due to a lower motor neuron injury, a bowel program including a high-fluid and high-fiber diet, stool softeners, and manual disimpaction if needed is effective. Pouring warm water, daily enemas, and abdominal massage are not appropriate.
A nurse assesses a client who is recovering from a lumbar laminectomy. Which complications should alert the nurse to urgently communicate with the health care provider? (Select all that apply.)
- A. Surgical discomfort.
- B. Redness and itching at the incision site.
- C. Incisional bulging.
- D. Clear drainage on the dressing.
- E. Sudden and severe headache.
Correct Answer: C,D,E
Rationale: Incisional bulging, clear drainage (possible CSF leak), and severe headache are emergencies post-laminectomy. Surgical discomfort and redness/itching are normal and not urgent.
After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the client's understanding. Which statements indicate a correct understanding of the teaching related to sexual effects of this injury? (Select all that apply.)
- A. I will explore other ways besides intercourse to please my partner.
- B. I will not be able to have an erection because of my injury.
- C. Ejaculation may not be as predictable as before.
- D. I may urinate with ejaculation but this will not cause infection.
- E. I should be able to have an erection with stimulation.
Correct Answer: C,D,E
Rationale: Men with injuries above T6 can often have reflex erections with stimulation. Ejaculation may be less predictable and mixed with urine, which is sterile and does not cause infection. Exploring alternative intimacy methods is also appropriate.