A nurse is assessing a client who has multiple sclerosis. Which of the following assessment findings should the nurse anticipate?
(Select All that Apply.)
Paresthesia
Nausea and vomiting
Dysphagia
Spasticity
Vertigo
Correct Answer : A,C,D,E
Choice A Reason:
Paresthesia is appropriate. Paresthesia, or abnormal sensations such as tingling, numbness, or burning, is a common neurological symptom in individuals with multiple sclerosis. It results from damage to the nerves or disruption of nerve signals in the central nervous system.
Choice B Reason:
Nausea and vomiting is inappropriate. While nausea and vomiting can occur in individuals with multiple sclerosis, they are not considered hallmark symptoms of the disease. These symptoms may be associated with other factors such as medications, autonomic dysfunction, or complications such as urinary tract infections.
Choice C Reason:
Dysphagia is appropriate. Dysphagia, or difficulty swallowing, is a common symptom in individuals with multiple sclerosis, particularly as the disease progresses. It can result from damage to the nerves that control swallowing muscles or from impaired coordination of swallowing reflexes.
Choice D Reason:
Spasticity is appropriate. Spasticity, or muscle stiffness and involuntary muscle contractions, is a common symptom in individuals with multiple sclerosis. It occurs due to damage to the nerve fibers that control muscle movement and can lead to difficulty with movement, walking, and muscle control.
Choice E Reason:
Vertigo is appropriate. Vertigo, or the sensation of spinning or dizziness, can occur in individuals with multiple sclerosis, particularly if lesions develop in areas of the brain involved in balance and coordination.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Keeping lights turned to medium level in the evening is incorrect. This intervention is aimed at reducing environmental stimuli, which may be appropriate for some patients with neurological conditions to minimize sensory overload and promote rest. However, it is not a specific intervention for preventing cerebral aneurysm rupture.
Choice B Reason:
Maintaining the head of the bed between 30 and 45° is correct. Keeping the head of the bed elevated can help reduce intracranial pressure and decrease the risk of cerebral aneurysm rupture or rebleeding in patients with aneurysmal subarachnoid hemorrhage. This position promotes venous drainage from the brain and helps prevent increases in intracranial pressure.
Choice C Reason:
Administering hypotonic intravenous solutions is incorrect. Hypotonic intravenous solutions have a lower osmolarity than blood plasma and can lead to cerebral edema, which may exacerbate intracranial pressure and increase the risk of cerebral aneurysm rupture. Isotonic solutions, such as normal saline (0.9% NaCl) or lactated Ringer's solution, are typically preferred for fluid resuscitation and maintenance in patients at risk of cerebral aneurysm rupture.
Choice D Reason:
Reposition the client every shift is incorrect. Repositioning the client every shift helps prevent complications associated with immobility, such as pressure ulcers, pneumonia, and venous thromboembolism. While important for overall patient care, repositioning alone does not directly address the risk of cerebral aneurysm rupture.
Correct Answer is B
Explanation
Choice A Reason:
"I have signed up for an aerobics class three times a week." This statement is incorrect. Participating in aerobics classes three times a week may not be suitable for someone with spinal stenosis, as certain movements and high-impact activities common in aerobics classes can exacerbate symptoms and increase the risk of injury to the spine.
Choice B Reason:
"I ride my bicycle every day." This statement is correct. Cycling is generally considered a low-impact exercise that can be beneficial for individuals with spinal stenosis, as it helps improve cardiovascular fitness without placing excessive stress on the spine. Riding a bicycle regularly may be a suitable exercise option for this client.
Choice C Reason:
"I like to jog a half a mile every day." This statement is incorrect. Jogging involves repetitive impact and can place significant stress on the spine, which may exacerbate symptoms of spinal stenosis. It is generally not recommended for individuals with spinal stenosis due to the high-impact nature of the activity.
Choice D Reason:
"I enjoy doing circuit training once a week.": Circuit training typically involves a combination of aerobic and strength-training exercises performed in rapid succession. While some components of circuit training, such as strength training, can be beneficial for individuals with spinal stenosis, the intensity and variety of exercises in circuit training may not be suitable for everyone with this condition.
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