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.
Nursing Test Bank
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 ["A","B","D"]
Explanation
Choice A Reason:
African American clients is appropriate. Research suggests that African Americans have a lower prevalence of MS compared to White Americans, but they tend to have more severe disease progression and higher disability rates when diagnosed with MS.
Choice B Reason:
White American clients: Individuals of European descent, including White Americans, have the highest prevalence of MS, particularly those of northern European ancestry. MS is more common in populations of northern European descent compared to other racial and ethnic groups.
Choice C Reason:
East Asian clients: East Asians, including individuals of Chinese, Japanese, and Korean descent, have historically had lower rates of MS compared to individuals of European descent. However, MS prevalence appears to be increasing in East Asian populations, possibly due to changes in lifestyle and environmental factors.
Choice D Reason:
Hispanic or Latino clients: Studies suggest that the prevalence of MS is lower in Hispanic/Latino populations compared to White Americans but higher than in African Americans. However, there is considerable variation in MS prevalence among different Hispanic/Latino subgroups.
Choice E Reason:
Navajo Indian clients: Native American populations, including Navajo Indians, have been reported to have a lower prevalence of MS compared to individuals of European descent. However, limited data are available on MS prevalence and incidence in specific Native American tribes, and more research is needed to fully understand the disease burden in these populations.
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