Three days after a female client with multiple sclerosis (MS) is admitted to the hospital with a severe urinary tract infection, she reports experiencing double vision. Which intervention should the nurse implement?

Correct Answer: A

Rationale: In this scenario, the correct intervention is to patch one eye and then the other every few hours (Option A). This intervention is based on the concept of occlusion therapy, which helps alleviate double vision (diplopia) by blocking the vision from one eye, allowing the brain to focus on the vision from the other eye, thus reducing the perception of double images. Option B, encouraging bedrest until diplopia resolves, is incorrect because bedrest does not address the underlying cause of diplopia and may not be effective in treating this symptom related to multiple sclerosis. Option C, limiting intake of oral fluids, is also incorrect as it is not a relevant intervention for diplopia. Hydration is important, especially in the case of urinary tract infection, but it does not directly address the double vision. Option D, administering artificial tear drops to both eyes, is not the most appropriate intervention for diplopia associated with multiple sclerosis. Artificial tear drops are typically used to relieve dry eyes and do not directly address the visual symptom of double vision. Educationally, understanding the rationale behind the intervention of patching one eye and rotating to the other can help nursing students comprehend the management of diplopia in patients with multiple sclerosis. It reinforces the concept of occlusion therapy and its application in clinical practice to improve patient outcomes.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Auscultate bowel sounds. Following a nephrectomy, abdominal pressure and nausea could indicate a paralytic ileus or bowel obstruction, which are potential postoperative complications. Auscultating bowel sounds is essential to assess for the presence or absence of bowel motility and potential blockages. Option A) Palpating the abdomen may exacerbate any potential complications, such as causing discomfort or rupturing a sensitive area post-surgery. It is not the best initial assessment for this situation. Option B) Measuring hourly urine output is important in monitoring kidney function post-nephrectomy but is not directly related to the presenting symptoms of abdominal pressure and nausea. Option C) Ambulating the client in the hallway may be beneficial for general postoperative recovery but is not the priority in this situation where abdominal symptoms need immediate assessment. Educationally, this question highlights the importance of recognizing potential postoperative complications in patients who have undergone nephrectomy. It emphasizes the need for thorough assessment skills and prioritizing assessments based on the client's symptoms to provide timely and appropriate care.

Correct Answer: B

Rationale: In this scenario, the correct answer is option B) Beef steak with steamed broccoli and orange slices. The client's presentation of chronic fatigue, low hemoglobin, and microcytic, hypochromic RBCs suggests iron deficiency anemia. Beef is a good source of heme iron, which is more readily absorbed by the body compared to non-heme iron found in plant-based foods. Broccoli and orange slices are rich in Vitamin C, which enhances iron absorption. Option A) Cheese pasta and a lettuce and tomato salad lacks significant iron content needed to address the anemia. Option C) Broiled white fish with a baked sweet potato is a healthy meal choice but does not provide sufficient iron. Option D) Grilled shrimp and seasoned rice with asparagus salad also lacks iron-rich foods necessary for addressing the anemia. Educationally, understanding the importance of dietary choices in managing pediatric cardiovascular disorders like anemia is crucial for nursing practice. Teaching patients about iron-rich foods and how to enhance iron absorption through dietary combinations can significantly impact their health outcomes. Nurses play a vital role in educating patients on nutrition to support their treatment and recovery.

Correct Answer: A

Rationale: The best initial nursing action in this scenario is to choose option A) Document negative results in the client's medical record. This is the correct choice because a Mantoux tuberculosis skin test showing 5 mm of erythema without induration after 62 hours is considered negative for tuberculosis infection. It is crucial for healthcare workers to have accurate documentation of test results in the medical record to ensure proper monitoring and follow-up. Option B) Repeat the test immediately on the opposite forearm is not necessary in this case as the initial test result is already negative. Repeating the test without a valid reason can lead to unnecessary discomfort for the healthcare worker and is not supported by evidence-based practice. Option C) Notify the healthcare provider for further evaluation is also not warranted in this situation as the test result is negative. Contacting the healthcare provider without a valid reason can lead to unnecessary burden on the provider and may result in inappropriate follow-up procedures. Option D) Schedule the worker for a chest X-ray is not indicated based on the negative Mantoux test result. Chest X-rays are typically ordered when there are signs and symptoms suggestive of active tuberculosis, which is not the case here. In an educational context, understanding the interpretation of diagnostic tests like the Mantoux test is crucial for nurses working in various clinical settings. It is essential for nurses to be able to accurately interpret test results, document findings appropriately, and follow evidence-based guidelines to provide optimal care for their patients.

Correct Answer: A

Rationale: Rationale: The correct answer is A) Protect cornea with lubricant and eye shields. In Guillain-Barre syndrome, paralysis of all extremities can lead to impaired blinking reflex, which puts the client at risk for corneal damage due to inadequate eye protection. By protecting the cornea with lubricant and eye shields, the nurse can prevent corneal abrasions and exposure keratitis, which can occur due to the inability to blink. Option B) Administer artificial tears every hour is incorrect because simply administering artificial tears does not address the need for protecting the cornea from damage. Option C) Encouraging the client to blink every 10 minutes is incorrect as the client's paralysis may prevent them from being able to blink voluntarily. Option D) Keeping the client's eyes closed with adhesive tape is incorrect because this can lead to further complications such as corneal abrasions and discomfort. Educational context: Understanding the importance of eye care in patients with Guillain-Barre syndrome is crucial for nursing care. By protecting the cornea with lubricant and eye shields, nurses can prevent serious eye complications and promote the overall well-being of the patient. This scenario highlights the need for vigilant assessment and proactive interventions to prevent potential complications in critically ill patients.