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 A
Explanation
Choice A reason:
Hypertension is a common manifestation of increased intracranial pressure (ICP). As ICP rises, the body attempts to maintain cerebral perfusion by increasing blood pressure. This compensatory mechanism helps ensure that the brain continues to receive adequate blood flow despite the elevated pressure.
Choice B reason:
Tinnitus, or ringing in the ears, is not a typical manifestation of increased ICP. While it can be a symptom of various conditions, it is not specifically associated with elevated intracranial pressure.
Choice C reason:
Hypotension, or low blood pressure, is not a manifestation of increased ICP. In fact, the body typically responds to increased ICP with hypertension to maintain cerebral perfusion. Hypotension would be concerning for other reasons but is not indicative of elevated intracranial pressure.
Choice D reason:
Tachycardia, or an increased heart rate, is not a primary manifestation of increased ICP. While changes in heart rate can occur with severe neurological conditions, hypertension is a more direct indicator of elevated intracranial pressure.
Correct Answer is C
Explanation
Choice A reason:
Assisting the client with active range of motion exercises is important for preventing complications such as contractures and maintaining mobility. However, it is not the priority intervention in the acute phase of a hemorrhagic stroke. The primary focus should be on stabilizing the client and monitoring their condition closely.
Choice B reason:
Maintaining strict bed rest to minimize cerebral blood flow is not appropriate for managing a hemorrhagic stroke. While bed rest may be necessary to prevent further injury, the priority is to monitor the client’s neurological status and vital signs to detect any changes that may indicate worsening of the condition.
Choice C reason:
Monitoring vital signs and neurological status frequently is the priority intervention for a client who has experienced a hemorrhagic stroke. Close monitoring allows the nurse to detect any changes in the client’s condition promptly and take appropriate action. This is crucial for preventing complications and ensuring timely intervention if the client’s condition deteriorates.
Choice D reason:
Administering anticoagulant medications is contraindicated in hemorrhagic stroke because they can exacerbate bleeding. Anticoagulants are used in ischemic stroke to prevent clot formation, but in hemorrhagic stroke, the focus is on controlling bleeding and stabilizing the client.