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:
Home care services provide medical and personal care to clients in their homes. While this option may be suitable for clients with less severe symptoms, a client with significant bilateral lower extremities muscle weakness may require more intensive rehabilitation services to improve mobility and function.
Choice B reason:
A sub-acute care facility provides care for clients who need more intensive services than those available in a traditional nursing home but do not require the full resources of a hospital. While this option may be appropriate for some clients, a rehabilitation facility is better suited for addressing the specific needs of a client with significant muscle weakness due to MS.
Choice C reason:
A rehabilitation facility is the most appropriate setting for a client with significant bilateral lower extremities muscle weakness due to MS. These facilities offer specialized programs and therapies designed to improve mobility, strength, and overall function. The client can receive comprehensive care from a multidisciplinary team, including physical therapists, occupational therapists, and neurologists.
Choice D reason:
A skilled nursing facility provides long-term care for clients with chronic conditions or disabilities. While these facilities offer medical care and assistance with daily activities, they may not provide the intensive rehabilitation services needed for a client with significant muscle weakness due to MS.
Correct Answer is B
Explanation
Choice a reason:
A negative-pressure isolation room is designed to prevent the spread of airborne infectious diseases by ensuring that air flows into the room but not out of it. This type of room is typically used for patients with diseases such as tuberculosis, measles, or COVID-19, which are spread through airborne particles. Scabies, however, is spread through direct skin-to-skin contact or by sharing personal items like bedding or clothing. Therefore, a negative-pressure isolation room is not necessary for a patient with scabies, as the primary mode of transmission is not airborne.
Choice b reason:
A private room is the most appropriate setting for a client with scabies. Scabies is highly contagious and can spread through direct skin-to-skin contact or by sharing personal items. Placing the client in a private room helps to prevent the spread of the mites to other patients and staff. In a private room, the client can be isolated effectively, and healthcare workers can implement contact precautions, such as wearing gloves and gowns, to minimize the risk of transmission. This approach ensures that the client receives appropriate care while protecting others from potential exposure.
Choice c reason:
A semi-private room with a client who has pediculosis capitis (head lice) is not suitable for a client with scabies. Although both conditions involve infestations, they are caused by different parasites and have different modes of transmission. Pediculosis capitis is spread through direct contact with infested hair or personal items, while scabies is spread through prolonged skin-to-skin contact. Placing a client with scabies in a semi-private room with another infested patient increases the risk of cross-contamination and further spread of both conditions. Therefore, this option is not recommended.
Choice d reason:
A positive-pressure isolation room is designed to protect immunocompromised patients from airborne pathogens by ensuring that air flows out of the room but not into it. This type of room is used for patients who need to be protected from infections, such as those undergoing chemotherapy or with severe immune deficiencies. Since scabies is not an airborne disease and does not pose a risk to immunocompromised patients in this manner, a positive-pressure isolation room is not appropriate for a client with scabies. The primary concern with scabies is preventing direct contact transmission, which is best managed in a private room.