Nokea
The client diagnosed with an acute exacerbation of multiple sclerosis is placed on high-dose intravenous injections of corticosteroid medication. Which nursing intervention should be implemented?
- A. Discuss discontinuing the proton pump inhibitor with the HCP.
- B. Hold the medication until after all cultures have been obtained.
- C. Monitor the client's serum blood glucose levels frequently
- D. Provide supplemental dietary sodium with the client's meals.
Correct Answer: C
Rationale: High-dose corticosteroids can cause hyperglycemia, so frequent monitoring of blood glucose levels is essential to prevent complications.
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When assessing the patient's ability to perform fine motor tasks, the nurse should:
- A. Ask the patient to perform tasks such as buttoning a shirt or writing a sentence.
- B. Measure the patient's blood pressure.
- C. Inspect the patient's gait and balance.
- D. Check the patient's oral hygiene.
Correct Answer: A
Rationale: Fine motor skills are assessed by tasks like buttoning a shirt or writing. Blood pressure, gait, and oral hygiene are unrelated to fine motor assessment.
Which assessment finding best supports the diagnosis of dissociative amnesia with fugue? The patient states:
- A. I cannot recall why I'm living in this town.
- B. I feel as if I'm living in a fuzzy dream state.
- C. I feel like different parts of my body are at war.
- D. I feel very anxious and worried about my problems.
Correct Answer: A
Rationale: The correct answer is A because the key feature of dissociative amnesia with fugue is the inability to remember important personal information. In this case, the patient cannot recall why they are living in the current town, indicating a significant gap in memory. Choice B describes a feeling of disorientation, not memory loss. Choice C suggests dissociative identity disorder, not dissociative amnesia. Choice D focuses on anxiety, which is not a primary symptom of dissociative amnesia with fugue.
As the community health nurse, you meet with Mrs. Rollo 1 week after discharge. She complains to you of increasing joint pain and stiffness despite adherence to the discharge plan for medication therapy and heat treatments. Which of the following aspects would you initially want to evaluate?
- A. Diet
- B. Balance between exercise and rest
- C. Use of fad diet or appliances
- D. Feelings of self-worth and self-concept
Correct Answer: B
Rationale: Imbalance between exercise and rest can exacerbate joint pain and stiffness.
Which of the following activity-related strategies would a nurse teach a client who is going home?
- A. Avoid fatigue and take frequent rest periods if needed
- B. Take deep breaths every 4 hours while awake
- C. Make your daily routine rigid so that you can remember what to do
- D. Avoid exposure to the outdoors
Correct Answer: A
Rationale: Rest periods help prevent exacerbation of symptoms.
How can the nurse assist the patient and family in coping with the long-term effects of a stroke?
- A. Informing family members that the patient will need assistance with almost all ADLs
- B. Explaining that the patient's prestroke behavior will return as improvement progresses
- C. Encouraging the patient and family members to seek assistance from family therapy or stroke support groups
- D. Helping the patient and family to understand the significance of residual stroke damage to promote problem solving and planning
Correct Answer: C
Rationale: Support groups and understanding residual damage aid in long-term adaptation to stroke effects