A nurse is caring for a client who has multiple sclerosis and reports a tightening feeling around their torso. Which of the following conditions should the nurse recognize this finding indicates?
Lhermitte's sign
Trigeminal neuralgia
MS hug
Paroxysmal spasms
The Correct Answer is C
A. Lhermitte's sign:
Lhermitte's sign is a neurological symptom characterized by a sensation of electric shock-like pain that radiates down the spine and into the limbs, typically triggered by flexing the neck forward. It is often described as shooting or stabbing pain and is commonly associated with lesions or damage to the cervical spinal cord. Lhermitte's sign is not associated with a tightening sensation around the torso but rather with shooting pain down the spine and limbs.
B. Trigeminal neuralgia:
Trigeminal neuralgia is a neurological condition characterized by severe, shooting pain along the trigeminal nerve, which supplies sensation to the face. The pain is typically triggered by activities such as chewing, speaking, or touching the face. Trigeminal neuralgia causes sudden, intense, electric shock-like pain in the face, particularly in the areas supplied by the trigeminal nerve (e.g., cheek, jaw, forehead). It is not associated with a tightening sensation around the torso.
C. MS hug:
The "MS hug" is a symptom experienced by some individuals with multiple sclerosis, characterized by a sensation of tightness, pressure, or squeezing around the chest, abdomen, or torso. It can feel like a band tightening around the body and may be described as a constricting or girdling sensation. The MS hug is caused by spasms or tightening of the muscles surrounding the rib cage or the intercostal muscles due to damage to the nerves that control muscle function in MS.
D. Paroxysmal spasms:
Paroxysmal spasms refer to sudden, involuntary muscle contractions or spasms that occur intermittently. These spasms can affect various parts of the body and are commonly associated with conditions like multiple sclerosis. However, they typically present as brief, sudden contractions rather than a persistent tightening sensation around the torso.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Check the client for a fecal impaction.
This intervention is important for managing autonomic dysreflexia because a fecal impaction can trigger autonomic dysreflexia by causing rectal distention. However, it is not the first action the nurse should take. Promptly addressing the immediate cause of autonomic dysreflexia is crucial to prevent complications.
B. Ensure the room temperature is warm.
This intervention is important for maintaining the client's comfort and preventing temperature-related complications. However, it is not the first action the nurse should take when suspecting autonomic dysreflexia. Immediate interventions to address the underlying cause of autonomic dysreflexia are necessary to prevent serious complications such as stroke or seizure.
C. Check the client's bladder for distention.
This is the correct action to take first. Bladder distention is one of the most common triggers of autonomic dysreflexia in individuals with spinal cord injuries. A distended bladder stimulates autonomic reflexes, leading to a sudden increase in blood pressure. Therefore, the nurse should assess the client's bladder for distention and initiate appropriate interventions such as catheterization to relieve urinary retention.
D. Raise the head of the bed.
While elevating the head of the bed can help reduce blood pressure in some situations, it is not the first action the nurse should take when suspecting autonomic dysreflexia. Elevating the head of the bed may exacerbate autonomic dysreflexia by increasing venous return and blood pressure. Therefore, addressing the underlying cause of autonomic dysreflexia, such as bladder distention, takes priority.
Correct Answer is ["0.6"]
Explanation
To calculate the dose of diazepam in mL, the nurse should use the formula:
Dose (mL) = Desired dose (mg) / Available dose (mg/mL)
Plugging in the values from the question, we get:
Dose (mL) = 3 mg / 5 mg/mL
Simplifying, we get:
Dose (mL) = 0.6 mL
Therefore, the nurse should administer 0.6 mL of diazepam IM.
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