A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. What intervention should the nurse include in this client's plan of care?- Skildor

Question 1 of 5

A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. What intervention should the nurse include in this client's plan of care?

A. Encourage the use of corrective lenses during the day B. Practice visual exercises that focus on a still object C. Alternate an eye patch from eye every 2 hours D. Teach techniques for scanning the environment

Correct Answer: D

Rationale: The correct intervention for a client with multiple sclerosis experiencing scotomas and limited peripheral vision is to teach techniques for scanning the environment. This intervention helps the client compensate for vision loss by learning how to scan and explore their surroundings effectively. Encouraging the use of corrective lenses may not address the issue of scotomas, and visual exercises focusing on a still object may not enhance peripheral vision. Alternating an eye patch every 2 hours is not typically indicated for scotomas in multiple sclerosis, making it an incorrect choice.

Question 2 of 5

After successful resuscitation, a client is given propranolol and transferred to the Intensive Coronary Care Unit (ICCU). On admission, magnesium sulfate 4 grams IV in 250 ml D5W at one gram/hour. Which assessment findings require immediate intervention by the nurse?

A. Dark amber urine draining via an indwelling catheter at a rate of 40 ml per hour B. Serum calcium of 9.0 mg/dl (2.2 mmol/L SI) and magnesium of 1.8 mg/dl or Eq/L (0.74 mmol/L SI) C. Sinus rhythm at 72 beats/minute and peripheral blood pressure of 99/62 D. Respiratory rate of 10 breaths per minute

Correct Answer: D

Rationale: The correct answer is D. A low respiratory rate of 10 breaths per minute is indicative of possible magnesium toxicity, which can be a serious condition requiring immediate intervention. It is a critical finding that needs prompt attention to prevent further complications. The other options are not as urgent: A - dark amber urine may indicate dehydration but does not require immediate intervention, B - serum calcium and magnesium levels are within normal limits, C - sinus rhythm and blood pressure values are also within normal range and do not require immediate action.

Question 3 of 5

A young adult male who is being seen at the employee health care clinic for an annual assessment tells the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficult indeed. Which response is best for the nurse to provide?

A. Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed. B. Encourage the client to seek genetic counseling to determine his risk for mental illness. C. Inform the client that his mother's schizophrenia has affected his psychological development. D. Tell the client that mental illness has a familial predisposition so he should see a psychiatrist.

Correct Answer: B

Rationale: Genetic counseling can help assess risk and provide guidance for the client's concerns about potential hereditary conditions.

Question 4 of 5

A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement?

A. Assess the client's need for pain medication B. Document the impending signs of death C. Inform the nurse manager of the client's status D. Communicate the client's status to the chaplain

Correct Answer: A

Rationale: Assessing the client's need for pain medication is the priority action as it ensures comfort at the end of life. Pain management is crucial in providing comfort and dignity to clients during their final moments. Documenting impending signs of death (choice B) is important but not the immediate priority over addressing the client's comfort. Updating the nurse manager (choice C) and informing the chaplain (choice D) can follow once the client's immediate needs are met.

Question 5 of 5

A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amounts of liquid stool. Which action should the nurse implement?

A. Digitally check the client for a fecal impaction B. Increase fluid intake to promote bowel regularity C. Provide a high-fiber diet to facilitate bowel movements D. Administer a stool softener

Correct Answer: A

Rationale: The correct answer is A: Digitally check the client for a fecal impaction. Small, frequent liquid stools following constipation may indicate a fecal impaction. This intervention is crucial to assess and address a potential impaction promptly. Choices B, increasing fluid intake, and C, providing a high-fiber diet, may help with bowel regularity in general cases, but they don't directly address the urgent concern of a possible impaction. Choice D, administering a stool softener, is not appropriate as the first action when a fecal impaction is suspected; it could worsen the condition by causing further liquid stool output without addressing the impaction.

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Skildor

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