You Selected: • "Avoid hot baths and showers." Correct response: • "Avoid hot baths and showers." Explanation: The nurse should instruct a client with MS to avoid hot baths and showers because they may exacerbate the disease. The nurse should encourage daytime naps because fatigue is a common symptom of MS. A client with MS doesn't require food or fluid restrictions. Question 23 For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs? You Selected: • Attaching braces or splints to each foot and leg Correct response: • Attaching braces or splints to each foot and leg Explanation: Attaching braces or splints to each foot and leg prevents footdrop (a lower leg contracture) by supporting the feet in proper alignment. Putting slippers on the client's
feet can't prevent footdrop because slippers are too soft to support the ankle joints. Crossing the ankles every 2 hours is contraindicated because it can cause excess pressure and damage veins, promoting thrombus formation. Placing hand rolls on the balls of each foot doesn't prevent contractures because hand rolls are too soft to support and hold the feet in proper alignment. Question 24 A client has an exacerbation of multiple sclerosis. The physician orders dantrolene, 25 mg P.O. daily. Which assessment finding indicates the medication is effective? You Selected: • Reduced muscle spasticity Correct response: • Reduced muscle spasticity Explanation: Dantrolene reduces muscle spacticity. It doesn't increase the ability to sleep or relieve constipation or pain. Question 25 A nurse is working on a surgical floor. The nurse must logroll a client following a: You Selected: • laminectomy. Correct response: • laminectomy. Explanation: The client who has had spinal surgery, such as laminectomy, must be logrolled to keep the spinal column straight when turning. The client who has had a thoracotomy or cystectomy may turn himself or may be assisted into a comfortable position. Under normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities immediately after surgery. Question 26 A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP? You Selected: • Administer stool softeners. Correct response: • Administer stool softeners. Explanation: Stool softeners reduce the risk of straining during a bowel movement, which can increase ICP by raising intrathoracic pressure and interfering with venous return. Coughing also increases ICP. Keeping the head in a midline position and avoiding extreme neck flexion prevents obstruction of venous outflow from the brain.
- Spring '17
- mrs. Vargovich
- Nursing, Intracranial pressure, Traumatic brain injury, Cerebrospinal fluid, Correct Response