A nurse is attending to a client with multiple sclerosis who reports a sensation of tightness around their torso. What condition should the nurse identify this symptom as indicating?
Trigeminal neuralgia
Lhermitte’s sign
MS hug
Paroxysmal spasms
The Correct Answer is C
Choice A rationale
Trigeminal neuralgia is a chronic pain condition that affects the trigeminal nerve, which carries sensation from your face to your brain. It does not cause a sensation of tightness around the torso.
Choice B rationale
Lhermitte’s sign is a symptom of multiple sclerosis and other neurological conditions where a person feels an electric shock-like sensation running down the spine and into the limbs. It does not cause a sensation of tightness around the torso.
Choice C rationale
The sensation of tightness around the torso in a patient with multiple sclerosis is often referred to as the “MS hug”. It is caused by a lesion or an area of active inflammation within the spinal cord.
Choice D rationale
Paroxysmal spasms are a type of muscle spasm experienced by some people with multiple sclerosis. These spasms are usually painful and involve the muscles of the legs, but they do not cause a sensation of tightness around the torso.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Bruising over the mastoid process, also known as Battle’s sign, is a classic clinical sign of a basilar skull fracture.
Choice B rationale
Pooling of blood and edema around the eyes, or ‘raccoon eyes’, is another sign of a basilar skull fracture.
Choice C rationale
The ability to recall how the injury occurred is not directly related to the presence of a basilar skull fracture. Memory loss or confusion could be symptoms of a traumatic brain injury, but they are not specific to a basilar skull fracture.
Choice D rationale
Chvostek’s sign is a clinical sign of hypocalcemia, not a basilar skull fracture
Correct Answer is B
Explanation
Choice A rationale
Swelling of the optic nerve, also known as papilledema, can be a sign of increased intracranial pressure (ICP). However, it is not a direct indicator of a worsening neurological condition.
Choice B rationale
The Glasgow Coma Scale (GCS) is a clinical tool used to assess a patient’s level of consciousness and neurological functioning. A decreasing GCS score indicates a worsening neurological condition, which could be due to increasing ICP12. Therefore, a decreasing GCS score is a direct indicator of a worsening neurological condition.
Choice C rationale
A blood pressure of 108/76 mm Hg is within the normal range and does not directly indicate a worsening neurological condition. However, drastic changes in blood pressure could potentially indicate a problem.
Choice D rationale
Changes in pupil size and shape can be a sign of increased ICP, but these changes are not specific to a worsening neurological condition. They could be due to various factors, including medication effects or damage to the cranial nerves.
Choice E rationale
A respiratory rate of 12/min is within the normal range for adults. Changes in respiratory patterns could potentially indicate a worsening neurological condition, but a rate of 12/min does not directly indicate this.
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