a client with multiple sclerosis is admitted with an acute exacerbation what is the nurses priority action
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Nursing Elites

HESI RN

HESI Exit Exam RN Capstone

1. A client with multiple sclerosis is admitted with an acute exacerbation. What is the nurse's priority action?

Correct answer: C

Rationale: The correct answer is C. Administering prescribed corticosteroids to reduce inflammation is the priority action when a client with multiple sclerosis is admitted with an acute exacerbation. Corticosteroids help manage symptoms during exacerbations and reduce inflammation. Monitoring vital signs and assessing muscle strength are important aspects of care but not the priority during an acute exacerbation. Educating the client on managing fatigue and preventing relapses is essential but can be addressed after the acute exacerbation has been managed.

2. A client presses the call bell and requests pain medication for a severe headache. To assess the quality of the client's pain, which approach should the nurse use?

Correct answer: C

Rationale: Asking the client to describe the pain is the most appropriate approach to assess the quality of pain. It provides valuable qualitative information that aids in understanding the nature, cause, and potential management strategies for the headache. While pain rating scales like the Wong-Baker Faces scale and using vital signs can help quantify pain severity, they do not offer specific descriptive details that can give insights into the type and characteristics of the pain experienced by the client.

3. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform?

Correct answer: B

Rationale: The correct answer is to perform a quick assessment of the client's condition when the high-pressure alarm goes off on the ventilator. This assessment is crucial to determine the cause of the alarm and the client's current status. Option A is incorrect because disconnecting the client from the ventilator without assessing the situation can be harmful. Option C is incorrect as the nurse should first assess the client before seeking additional help. Option D is incorrect because resetting the alarm without understanding the underlying issue may lead to potential risks to the client.

4. A client with chronic liver disease develops jaundice. What is the most important assessment the nurse should perform?

Correct answer: D

Rationale: In a client with chronic liver disease developing jaundice, the most important assessment the nurse should perform is to monitor the client’s urine output closely. Jaundice can indicate worsening liver function, so monitoring urine output helps assess kidney function and fluid balance, which are critical in chronic liver disease. Assessing the client’s skin for lesions or sores (Choice A) may be relevant for dermatological conditions but is not the priority in this case. Monitoring liver function tests (Choice B) is important but may not provide immediate information on the client’s current status. Assessing for changes in mental status and behavior (Choice C) is important for detecting hepatic encephalopathy but does not directly address the immediate concern of fluid balance and kidney function in the presence of jaundice.

5. A client is prescribed metformin for type 2 diabetes. What should the nurse emphasize in the client's teaching?

Correct answer: C

Rationale: The correct answer is to avoid alcohol consumption while taking metformin. Alcohol can increase the risk of lactic acidosis when combined with metformin. Choice A is incorrect because metformin is usually recommended to be taken with meals to reduce GI upset. Choice B is important but not the priority; muscle pain is more commonly associated with other diabetes medications. Choice D is incorrect because metformin typically does not cause hypoglycemia but rather helps control blood sugar levels in type 2 diabetes.

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