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 B
Explanation
Choice A reason:
A gradual onset of headache is more characteristic of other types of headaches or conditions, such as tension headaches or migraines. Hemorrhagic strokes, particularly those caused by a ruptured cerebral aneurysm, typically present with a sudden and severe headache, often described as the “worst headache of my life.” This sudden onset is due to the rapid accumulation of blood in the brain, which increases intracranial pressure and causes immediate symptoms.
Choice B reason:
Changes in consciousness are a common manifestation of a hemorrhagic stroke. The sudden bleeding into the brain can disrupt normal brain function, leading to symptoms such as confusion, lethargy, or loss of consciousness. These changes occur rapidly and are a key indicator of a serious neurological event. The nurse should be vigilant for any alterations in the client’s level of consciousness, as this can signify worsening of the condition and the need for immediate medical intervention.
Choice C reason:
A gradual onset of several hours is not typical for hemorrhagic strokes. These strokes usually present with sudden and severe symptoms due to the abrupt rupture of a blood vessel in the brain. The rapid increase in intracranial pressure from the bleeding causes immediate and severe symptoms, rather than a slow progression over hours.
Choice D reason:
A history of neurologic deficits lasting less than 1 hour is more indicative of a transient ischemic attack (TIA), also known as a mini-stroke. TIAs are temporary and resolve within a short period without causing permanent damage. In contrast, a hemorrhagic stroke caused by a ruptured cerebral aneurysm results in immediate and severe symptoms that do not resolve quickly and require urgent medical attention.
Correct Answer is B
Explanation
Choice A: A negative-pressure isolation room
A negative-pressure isolation room is typically used for patients with airborne infections, such as tuberculosis or measles, to prevent the spread of infectious agents through the air. Scabies, however, is primarily transmitted through direct skin-to-skin contact and occasionally through contact with contaminated clothing or bedding. Therefore, a negative-pressure isolation room is not necessary for a scabies patient1.
Choice B: A private room
A private room is the most appropriate choice for a client with scabies. This type of room helps prevent the spread of the infestation to other patients and allows for better control of the environment. Scabies is highly contagious and can spread through direct contact with the infested person or indirectly through contaminated items. Isolating the patient in a private room minimizes the risk of transmission and allows for proper infection control measures to be implemented2.
Choice C: A semi-private room with a client who has pediculosis capitis
Placing a scabies patient in a semi-private room with another patient, even one with a different parasitic infection like pediculosis capitis (head lice), is not advisable. Both conditions are highly contagious, and cohabitation increases the risk of cross-contamination and further spread of both infestations. Each condition requires specific treatment and isolation protocols to effectively manage and prevent outbreaks3.
Choice D: A positive-pressure isolation room
A positive-pressure isolation room is designed to protect immunocompromised patients from external contaminants by ensuring that air flows out of the room rather than in. This type of room is not suitable for a scabies patient, as it does not address the primary mode of transmission for scabies, which is direct contact. The focus for scabies management should be on preventing direct and indirect contact with others4.