Nokea
A patient with MS has been admitted to the hospital following an acute exacerbation. When planning the patient's care, the nurse addresses the need to enhance the patient's bladder control. What aspect of nursing care is most likely to meet this goal?
- A. Establish a timed voiding schedule.
- B. Avoid foods that change the pH of urine.
- C. Perform intermittent catheterization q6h.
- D. Administer anticholinergic drugs as ordered.
Correct Answer: A
Rationale: A timed voiding schedule promotes bladder control in MS by training the bladder. Catheterization and anticholinergics are not first-line, and urine pH is irrelevant.
You may also like to solve these questions
A patient with Guillain-Barr?© syndrome has experienced a sharp decline in vital capacity. What is the nurse's most appropriate action?
- A. Administer bronchodilators as ordered.
- B. Remind the patient of the importance of deep breathing and coughing exercises.
- C. Prepare to assist with intubation.
- D. Administer supplementary oxygen by nasal cannula.
Correct Answer: C
Rationale: A sharp decline in vital capacity in Guillain-Barr?© syndrome indicates respiratory muscle weakness, necessitating preparation for intubation to ensure adequate oxygenation. Bronchodilators and oxygen are insufficient, and breathing exercises may be impossible.
A 33-year-old patient presents at the clinic with complaints of weakness, incoordination, dizziness, and loss of balance. The patient is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS?
- A. Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes
- B. Flexor spasm, clonus, and negative Babinski's reflex
- C. Blurred vision, intention tremor, and urinary hesitancy
- D. Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs
Correct Answer: C
Rationale: Blurred vision (optic neuritis), intention tremor, and urinary hesitancy are typical MS symptoms due to demyelination. Deep tendon reflexes are hyperactive, Babinski's is positive, and abdominal reflexes are absent in MS.
The critical care nurse is caring for a 25-year-old man admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this patient?
- A. Maintaining the patient's functional independence
- B. Providing health education
- C. Monitoring neurologic status closely
- D. Promoting mobility
Correct Answer: C
Rationale: Close neurologic monitoring is critical for brain abscess patients to detect changes like increased intracranial pressure. Independence, education, and mobility are secondary in acute care.
A male patient presents to the clinic complaining of a headache. The nurse notes that the patient is guarding his neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the patient may have meningitis. What is another well-recognized sign of this infection?
- A. Negative Brudzinski's sign
- B. Positive Kernig's sign
- C. Hyperpatellar reflex
- D. Sluggish pupil reaction
Correct Answer: B
Rationale: A positive Kernig's sign, where leg extension causes pain due to meningeal irritation, is a classic sign of meningitis. Brudzinski's sign is positive, not negative, and reflexes or pupil reactions are not typical signs.
A 35-year-old woman is diagnosed with a peripheral neuropathy. When making her plan of care, the nurse knows to include what in patient teaching? Select all that apply.
- A. Inspect the lower extremities for skin breakdown.
- B. Footwear needs to be accurately sized.
- C. Immediate family members should be screened for the disease.
- D. Assistive devices may be needed to reduce the risk of falls.
- E. Dietary modifications are likely necessary.
Correct Answer: A,B,D
Rationale: Peripheral neuropathy requires inspecting for skin breakdown, proper footwear, and assistive devices to prevent falls. It is not genetic, and diet is unrelated.