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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View Related questions
Correct Answer is ["C","D","E"]
Explanation
Choice A reason:
Going automatically into the client’s bedroom without permission is inappropriate and can be seen as an invasion of privacy. The nurse should always seek consent and respect the client’s personal space. Building trust and maintaining professional boundaries are crucial in home care settings.
Choice B reason:
While it is courteous to thank the client for arranging a home visit, it is not a critical action that directly impacts the care provided. The focus should be on assessing the client’s needs and establishing a care plan.
Choice C reason:
Arranging mutual future visits is an appropriate action. It helps to establish a consistent care schedule, ensuring that the client receives ongoing support and monitoring. This is particularly important for managing chronic conditions like diabetes, where regular follow-up is essential for effective management.
Choice D reason:
Asking how the client is managing at home is a crucial part of the initial assessment. It provides the nurse with valuable information about the client’s current health status, challenges, and needs. This information is essential for developing a personalized care plan that addresses the client’s specific circumstances.
Choice E reason:
Sitting down and discussing with the client and family members is an important step in the initial home care visit. It helps to build rapport, understand the client’s support system, and involve family members in the care process. This collaborative approach ensures that everyone is informed and can contribute to the client’s care and well-being.
Correct Answer is C
Explanation
Choice A reason:
Inserting a padded tongue blade into the client’s mouth is not recommended and can be dangerous. During a seizure, there is a risk of causing injury to the client’s mouth or teeth, and it can also obstruct the airway. The correct approach is to ensure the client’s safety by preventing injury, not by inserting objects into their mouth.
Choice B reason:
Restraining the client during a seizure is not advised. Restraints can cause additional harm and do not prevent the seizure from occurring. Instead, the focus should be on protecting the client from injury by ensuring a safe environment and allowing the seizure to run its course.
Choice C reason:
Moving objects away from the client is a crucial step in ensuring their safety during a seizure. This action helps prevent the client from hitting or injuring themselves on nearby objects. Creating a safe space around the client is one of the primary goals during a seizure to minimize the risk of injury.
Choice D reason:
Placing the client on their back is not recommended during a seizure. Instead, the client should be placed on their side if possible, to help keep the airway clear and reduce the risk of aspiration. This position also allows for better monitoring of the client’s breathing and overall condition.