Nokea
The nurse is obtaining a health history and physical assessment from a patient with possible multiple sclerosis (MS). Which of the following assessment should the nurse include?
- A. Assess for the presence of chest pain.
- B. Inquire about any urinary tract problems.
- C. Inspect the skin for rashes or discoloration.
- D. Question the patient about any increase in libido.
Correct Answer: B
Rationale: Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.
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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 caring for a patient with Parkinson's disease who has decreased tongue mobility and an inability to move the facial muscles. Which of the following nursing diagnoses is of highest priority?
- A. Activity intolerance related to immobility
- B. Toileting self-care deficit related to impaired mobility
- C. Ineffective health management related to difficulty managing complex treatment regimen
- D. Imbalanced nutrition: less than body requirements related to insufficient dietary intake
Correct Answer: D
Rationale: The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing. The other diagnoses also may be appropriate for a patient with Parkinson's disease, but the data do not indicate they are current problems for this patient.
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 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.
The nurse is caring for a patient with myasthenia gravis who has had a thymectomy and receives the usual dose of pyridostigmine. An hour later, the patient has nausea and severe abdominal cramps. Which of the following actions should the nurse take first?
- A. Auscultate the patient's bowel sounds.
- B. Notify the patient's health care provider.
- C. Administer the prescribed PRN antiemetic drug.
- D. Give the scheduled dose of prednisone.
Correct Answer: B
Rationale: The patient's history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis.