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
“I may experience urinary incontinence.”
“I should not exercise because this may trigger an exacerbation.”
“I need to check the water temperature before I take a bath.”
“I may experience visual disturbances.”
“I should alternate the eye patch every other day to help with the double vision.”
Correct Answer : B,E
Choice A reason:
“I may experience urinary incontinence.” This statement is correct. Urinary incontinence is a common symptom of MS due to the disease’s impact on the nervous system. The client does not need additional teaching regarding this statement.
Choice B reason:
“I should not exercise because this may trigger an exacerbation.” This statement indicates a need for additional teaching. Regular exercise is beneficial for individuals with MS and can help improve strength, mobility, and overall well-being. The nurse should educate the client on safe and appropriate exercise routines.
Choice C reason:
“I need to check the water temperature before I take a bath.” This statement is correct. Clients with MS may have impaired sensation and are at risk for burns if the water is too hot. Checking the water temperature is a necessary precaution.
Choice D reason:
“I may experience visual disturbances.” This statement is correct. Visual disturbances, such as blurred vision or double vision, are common symptoms of MS. The client does not need additional teaching regarding this statement.
Choice E reason:
“I should alternate the eye patch every other day to help with the double vision.” This statement indicates a need for additional teaching. While using an eye patch can help manage double vision, it should be alternated more frequently, typically every few hours, to prevent strain on the covered eye.
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Correct Answer is C
Explanation
Choice A reason:
“It’s not unusual to feel that way at first, but once you learn the routine, you’ll enjoy it.” While this response acknowledges the client’s feelings, it does not provide specific information about the benefits of cardiac rehabilitation. The client needs to understand how rehabilitation can help them recover and improve their quality of life.
Choice B reason:
“Diet and exercise are good for you and good for your heart.” This statement is true but too general. It does not address the client’s specific concerns about the purpose and benefits of cardiac rehabilitation. The client needs more detailed information about how the program can help them.
Choice C reason:
“Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely.” This response directly addresses the client’s concerns and provides clear information about the benefits of cardiac rehabilitation. It explains that while the damage cannot be reversed, rehabilitation can help the client regain strength, improve cardiovascular health, and safely return to their daily activities.
Choice D reason:
“Your doctor is the expert here, and I’m sure they would only recommend what is best for you.” While this statement supports the doctor’s recommendation, it does not provide the client with specific information about the benefits of cardiac rehabilitation. The client needs to understand how the program can help them personally.
Correct Answer is B
Explanation
Choice A reason:
Administering thrombolytics is not the first action the nurse should take. Thrombolytics are used to treat ischemic strokes, but their administration requires a thorough assessment and confirmation of the diagnosis through imaging studies. Immediate action is needed to ensure the client’s safety and initiate the stroke protocol.
Choice B reason:
Calling for help is the first action the nurse should take. The client is exhibiting signs of a possible stroke, and immediate medical intervention is required. Calling for help ensures that the stroke team or emergency response team is activated promptly to provide the necessary care.
Choice C reason:
Providing the client with water to test the gag reflex is not appropriate in this situation. The client may have difficulty swallowing, and giving water could lead to aspiration. The priority is to ensure the client’s safety and initiate the stroke protocol.
Choice D reason:
Performing carotid massage is not indicated for a client with new right-sided weakness and slurred speech. Carotid massage is used to manage certain types of arrhythmias, but it is not appropriate for suspected stroke. The focus should be on immediate assessment and intervention.