A nurse in a clinic is reinforcing teaching with a group of clients about preventing low back pain and injury. Which of the following statements should the nurse identify as an indication that the client requires further clarification?
I’ll wear low-heeled shoes from now on.
I’ll carry heavy objects close to my body.
I’ll sit with my knees lower than my hips.
I’ll do exercises that strengthen my abdominal muscles.
The Correct Answer is C
A. Wearing low-heeled shoes is advisable to promote better posture and alignment, so this statement is appropriate.
B. Carrying heavy objects close to the body is a recommended practice for preventing back injury, indicating correct understanding.
C. Sitting with knees lower than hips can lead to poor posture and increased strain on the lower back, indicating a need for further clarification. The correct position should have the knees level or slightly higher than the hips.
D. Strengthening abdominal muscles is beneficial for back support and injury prevention, indicating the client understands the concept.
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Correct Answer is B
Explanation
A. Primary progressive multiple sclerosis is characterized by a gradual progression of symptoms without relapses, so this does not match the client's pattern.
B. Relapsing-remitting multiple sclerosis is defined by episodes of exacerbation (active symptoms) followed by periods of remission (no symptoms), which aligns with the client's description.
C. Secondary progressive multiple sclerosis follows an initial relapsing-remitting course but leads to a more continuous decline in function, so it does not match the pattern described.
D. Clinically isolating syndrome refers to a single episode of neurological symptoms but does not indicate the pattern of relapses and remissions typical of relapsing-remitting multiple sclerosis.
Correct Answer is D
Explanation
A. The nurse should measure the apical pulse for a full minute (not 30 seconds) before administering digoxin. If the pulse is below 60 beats per minute, the medication should be withheld, making this option incomplete.
B. Digoxin should be withheld if the heart rate is below 60/min, not above 100/min. This statement does not reflect proper nursing protocol.
C. Clients taking digoxin should maintain adequate potassium levels, so advising low potassium intake is incorrect. Foods rich in potassium are encouraged.
D. Monitoring for symptoms such as nausea, vomiting, and yellow vision is essential, as these may indicate digoxin toxicity, making this option correct.