Nokea
The nurse is creating an education plan for a client who has a recent diagnosis of Multiple Sclerosis (MS). Which of the following interventions should the nurse include in the client's plan?
- A. Recommend the client engage in high-impact, vigorous exercises to improve muscle strength
- B. Teach the client stress management techniques such as deep breathing and meditation
- C. Advise the client to avoid social interactions to minimize stress
- D. Encourage the client to void every hour
Correct Answer: B
Rationale: The correct answer is B: Teach the client stress management techniques such as deep breathing and meditation. This intervention is appropriate for a client with MS as stress can exacerbate symptoms. Deep breathing and meditation are proven techniques to reduce stress levels, promote relaxation, and improve overall well-being. By incorporating stress management techniques into the education plan, the nurse can help the client cope better with the emotional and physical challenges of living with MS.
Choice A is incorrect because high-impact, vigorous exercises can actually worsen symptoms and fatigue in clients with MS. Choice C is incorrect as social interactions can provide emotional support and should not be avoided. Choice D is incorrect as there is no specific indication for encouraging the client to void every hour in the context of MS.
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A nurse is assessing a client who reports a severe headache and stiff neck. The nurse's assessment reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first?
- A. Decrease bright lights
- B. Implement droplet precautions
- C. Initiate IV access
- D. Administer antibiotics
Correct Answer: B
Rationale: The correct answer is B: Implement droplet precautions. This is the first action the nurse should take because positive Kernig's and Brudzinski's signs suggest the client may have meningitis, which is highly contagious through respiratory droplets. Implementing droplet precautions will help prevent the spread of the infection to others. Decreasing bright lights (A) may be helpful for the client's comfort but is not the priority. Initiating IV access (C) and administering antibiotics (D) are important interventions but should be done after implementing precautions to prevent transmission of the infection.
A nurse is caring for a client who has experienced a hemorrhagic stroke. Which intervention should the nurse prioritize when providing care to the client?
- A. Assisting the client with active range of motion exercises
- B. Maintaining strict bed rest to minimize cerebral blood flow
- C. Monitoring vital signs and neurological status frequently
- D. Administering anticoagulant medications as prescribed
Correct Answer: C
Rationale: The correct answer is C: Monitoring vital signs and neurological status frequently. This is crucial in caring for a client who has experienced a hemorrhagic stroke as it allows for early detection of any changes in condition such as increased intracranial pressure or neurological deterioration. Vital signs provide important information about the client's overall condition, while neurological status assessments help in evaluating brain function and detecting any signs of worsening stroke symptoms. This intervention is essential for prompt intervention and preventing further complications.
Incorrect answers:
A: Assisting the client with active range of motion exercises - This is not a priority in the acute phase of a hemorrhagic stroke as it can potentially worsen the condition.
B: Maintaining strict bed rest to minimize cerebral blood flow - While bed rest is important, strict bed rest may not be necessary, and minimizing cerebral blood flow is not the primary goal.
D: Administering anticoagulant medications as prescribed - Anticoagulants are contraindicated in hemorrhagic strokes as
The nurse is providing education to a client who is newly diagnosed with Multiple Sclerosis (MS). Which client statements indicate the need for additional teaching? SELECT ALL THAT APPLY
- A. I may experience urinary incontinence
- B. I should not exercise because this may trigger an exacerbation
- C. I need to check the water temperature before I take a bath
- D. I may experience visual disturbances
- E. I should alternate the eye patch every other day to help with the double vision
Correct Answer: B,E
Rationale: Correct Answer: B, E
Rationale:
- Choice B is incorrect because exercise is beneficial for MS clients, improving strength and mood. Avoiding exercise is not recommended.
- Choice E is incorrect because alternating the eye patch can worsen double vision. Consistent use of the eye patch is more effective.
- Choices A, C, and D are correct statements that indicate proper understanding of MS symptoms and self-care.
A nurse enters the room of a client and discovers the client with new right-sided weakness and slurred speech. Which of the following actions should the nurse take?
- A. Administer thrombolytics
- B. Call for help
- C. Provide the client with water to test the gag reflex
- D. Perform carotid massage
Correct Answer: B
Rationale: The correct action is to call for help (Choice B). This is because the client is displaying signs of a possible stroke, such as right-sided weakness and slurred speech. Time is critical in stroke management, and calling for help immediately can ensure the client receives prompt medical attention, such as a CT scan to confirm the diagnosis and appropriate treatment. Administering thrombolytics (Choice A) should only be done after a confirmed diagnosis to avoid potential harm. Providing water to test the gag reflex (Choice C) and performing carotid massage (Choice D) are not appropriate actions for a suspected stroke and could delay necessary interventions.
The community health nurse is educating new nurses on the spread of infectious diseases. The nurse utilizes which of the following approaches to explain the factors that allow the reproduction and spread of infectious disease?
- A. Epidemiologic triangle
- B. Levels of prevention
- C. Natural history of disease
- D. Health Promotion
Correct Answer: A
Rationale: The correct answer is A: Epidemiologic triangle. This model explains infectious disease spread by considering the interactions between the host, agent, and environment. Host factors include susceptibility to the disease, agent factors refer to the infectious microorganism, and environmental factors influence transmission. This approach helps new nurses understand the complex interplay of factors leading to disease transmission. Choices B, C, and D are incorrect because they do not specifically address the factors involved in the reproduction and spread of infectious diseases. Level of prevention refers to actions taken to prevent disease, natural history of disease focuses on disease progression, and health promotion aims to improve overall health but does not directly explain disease spread.