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 ["A","B","C","E"]
Explanation
Choice A reason:
Identification of resources to meet anticipated needs is a critical component of disaster planning. Nurses play a key role in identifying the resources required for effective disaster response, including medical supplies, personnel, and equipment. This ensures that the hospital is prepared to meet the needs of patients during a disaster.
Choice B reason:
Participation in comprehensive annual drills is essential for disaster preparedness. Nurses are involved in these drills to practice and refine their response skills, ensuring they are ready to act effectively in a real disaster. Drills help identify gaps in the disaster plan and provide opportunities for improvement.
Choice C reason:
Internal and external communications are vital during a disaster. Nurses are involved in establishing and maintaining communication channels within the hospital and with external agencies. Effective communication ensures coordination and timely response, which are crucial for managing a disaster situation.
Choice D reason:
Performing duties outside the typical job description may occur during a disaster, but it is not a primary component of the disaster plan. The focus is on ensuring that all staff are prepared to perform their roles effectively. While flexibility is important, the disaster plan should primarily outline specific roles and responsibilities.
Choice E reason:
Development of a decontamination plan is an important aspect of disaster preparedness, especially in scenarios involving hazardous materials. Nurses contribute to creating and implementing decontamination protocols to protect patients and staff from exposure to harmful substances.
Correct Answer is B
Explanation
Choice A reason:
Chewing the tablet before swallowing is not the correct method of administration for Sumatriptan (Imitrex) tablets. These tablets are designed to be swallowed whole. Chewing them could affect the medication’s efficacy and absorption.
Choice B reason:
“If you experience chest pain, call your physician immediately.” This instruction is crucial because Sumatriptan can cause serious cardiovascular side effects, including chest pain, which may indicate a heart attack or other serious condition. Clients need to be aware of this potential side effect and seek immediate medical attention if it occurs.
Choice C reason:
Taking Sumatriptan daily to prevent headaches is incorrect. Sumatriptan is used to treat acute migraine attacks and is not intended for daily use as a preventive medication. Using it daily could lead to medication overuse headaches and other adverse effects.
Choice D reason:
“Repeat dose in 1 hour for unrelieved headache” is partially correct but incomplete. The correct instruction is to repeat the dose after 2 hours if the headache is not relieved, up to a maximum of two doses in 24 hours. Clients should follow the specific dosing instructions provided by their healthcare provider.