Nokea
The nurse is caring for a patient with multiple sclerosis (MS) who has urinary retention caused by a flaccid bladder. Which of the following actions should the nurse plan to take?
- A. Teach the patient how to perform self-catheterization
- B. Decrease the patient's fluid intake in the evening
- C. Suggest the use of incontinence briefs for nighttime use only
- D. Assist the patient to the commode every 2 hours during the day.
Correct Answer: A
Rationale: Bladder control is a major problem for many patients with MS. Although anticholinergics may be beneficial for some patients to decrease spasticity, other patients may need to be taught self-catheterization. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection (UTI) and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying.
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The nurse is caring for a patient with multiple sclerosis (MS) who is to begin treatment with glatiramer acetate. Which of the following information should the nurse include in patient teaching?
- A. Recommendation to drink at least 3-4 L of water daily
- B. Need to avoid driving or operating heavy machinery
- C. How to draw up and administer injections of the medication
- D. Use of contraceptive methods other than oral contraceptives
Correct Answer: C
Rationale: Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for birth control. There is no need to avoid driving or drink large fluid volumes when taking glatiramer.
The nurse is teaching a patient about management of migraine headaches. Which of the following patient statements indicates that the teaching has been effective?
- A. I will take the topiramate as soon as any headaches start.
- B. I should avoid taking Aspirin and sumatriptan at the same time.
- C. I will try to lie down in a dark and quiet area when the headaches begin.
- D. A glass of wine might help me relax and prevent headaches from developing.
Correct Answer: C
Rationale: It is recommended that the patient with a migraine rest in a dark, quiet area. Topiramate is used to prevent migraines and must be taken for several months to determine effectiveness. Aspirin or other nonsteroidal anti-inflammatory medications can be taken with the triptans. Alcohol may precipitate migraine headaches.
A female patient who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which of the following responses by the nurse is accurate?
- A. MS symptoms may be worse after the pregnancy.
- B. Women with MS frequently have premature labour.
- C. Symptoms of MS are likely to become worse during pregnancy.
- D. MS is associated with a slightly increased risk for congenital defects.
Correct Answer: A
Rationale: During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Onset of labour is not affected by MS.
The nurse is assessing a patient at the health clinic who has a severe migraine headache and tells the nurse about having four similar headaches in the last 3 months. Which of the following actions should the nurse take initially?
- A. Refer the patient for stress counselling.
- B. Ask the patient to keep a headache diary.
- C. Suggest the use of muscle-relaxation techniques.
- D. Teach about the effectiveness of the triptan drugs.
Correct Answer: B
Rationale: The initial nursing action should be further assessment of the precipitating causes of the headaches, quality, and location of pain, etc. Stress reduction, muscle relaxation, and the triptan drugs may be helpful, but more assessment is needed first.
The nurse is assessing a patient with myasthenia gravis. Which of the following parameters is most important for the nurse to assess?
- A. Check pupillary size.
- B. Monitor grip strength.
- C. Observe respiratory effort.
- D. Assess level of consciousness.
Correct Answer: C
Rationale: Because respiratory insufficiency may be life-threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.