Nokea
A client with multiple sclerosis.
The nurse is performing discharge teaching on a client with multiple sclerosis. It is MOST important for the nurse to include which of the following instructions?
- A. Ambulate as tolerated every day.
- B. Avoid overexposure to heat or cold.
- C. Perform stretching and strengthening exercises.
- D. Participate in social activities.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is encouraged to ambulate as tolerated (2) correct-overexposure to heat or cold may cause damage related to the changes in sensation (3) client is encouraged to participate in an exercise program to include ROM, stretching, and strengthening exercises (4) client is encouraged to continue usual activities as much as possible, including social activities
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The client with a suspected pituitary tumor will most likely exhibit symptoms of:
- A. Alteration in visual acuity
- B. Frequent diarrhea
- C. Alterations in blood glucose
- D. Urticaria
Correct Answer: A
Rationale: Pituitary tumors can compress the optic chiasm, leading to visual disturbances. Diarrhea , blood glucose changes , and urticaria are less commonly associated with pituitary tumors.
A client with a T6 injury 6 months ago develops facial flushing and a BP of 210/106. After elevating the head of the bed, which is the most appropriate nursing action?
- A. Notify the RN.
- B. Assess the client for a distended bladder.
- C. Apply oxygen at 3 L/min.
- D. Increase the IV fluids.
Correct Answer: B
Rationale: The symptoms suggest autonomic dysreflexia, often triggered by a distended bladder or bowel in clients with spinal cord injuries above T6. Assessing and addressing the trigger, such as a distended bladder, is the most appropriate action. Notifying the RN may be necessary but is not the immediate action, so answer A is incorrect. Oxygen and increased IV fluids do not address the cause, so answers C and D are incorrect.
The nurse is teaching a client with a new diagnosis of epilepsy about phenytoin (Dilantin). Which of the following statements by the client indicates a need for further teaching?
- A. I should brush my teeth regularly.
- B. I should report any skin rashes to my doctor.
- C. I should avoid drinking grapefruit juice.
- D. I should stop this medication if my seizures stop.
Correct Answer: D
Rationale: Stopping phenytoin when seizures stop is incorrect, as epilepsy often requires lifelong treatment to prevent recurrence. Options A, B, and C are correct: oral hygiene prevents gingival hyperplasia, rashes may indicate hypersensitivity, and grapefruit juice does not significantly affect phenytoin.
The parents of a one-month-old boy bring their son to the clinic for evaluation of a possible right dislocated hip.
- A. Which symptom will the nurse observe in a one-month-old with unilateral right hip dislocation?
- B. Limited adduction of the right leg.
- C. Uneven gluteal fold and thigh creases.
- D. Increase in length of the right limb.
- E. Internal rotation of the right leg.
Correct Answer: B
Rationale: Unilateral hip dislocation causes uneven gluteal folds and thigh creases, with deeper and longer folds on the affected side due to hip displacement. Limited abduction (not adduction), shortened limb length, and variable rotation are more typical findings.
The client has recently had a colostomy. The nurse is providing home care and is teaching the client about care of his colostomy. Which comment by the client indicates understanding of the care of his colostomy?
- A. I will use hot water to irrigate the colostomy.'
- B. If my skin gets red, I will put alcohol on it.'
- C. I will irrigate the colostomy at the same time each day.'
- D. I should do the irrigation while lying in bed.'
Correct Answer: C
Rationale: Regularly timed colostomy irrigation promotes predictable bowel patterns, indicating understanding. Hot water, alcohol, or bed irrigation are incorrect.