A nurse is caring for 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 rationale
Paresthesia, characterized by abnormal sensations such as tingling, numbness, or "pins and needles," is a common symptom in multiple sclerosis. This occurs due to demyelination and subsequent damage to sensory nerve pathways in the central nervous system, disrupting the normal transmission of sensory signals from the periphery to the brain. These sensory disturbances can fluctuate in intensity and location.
Choice B rationale
Nausea and vomiting are generally not considered primary or common assessment findings directly related to the pathophysiology of multiple sclerosis. While a client with MS might experience nausea and vomiting due to other co-existing conditions, medication side effects, or central nervous system lesions affecting areas involved in emesis (e.g., area postrema), it is not a hallmark symptom of the disease itself.
Choice C rationale
Dysphagia, or difficulty swallowing, is a significant symptom in multiple sclerosis, especially as the disease progresses. Demyelination and lesions in the brainstem or cranial nerves responsible for coordinating the complex muscular movements of swallowing can impair the pharyngeal and esophageal phases, increasing the risk of aspiration and nutritional deficiencies.
Choice D rationale
Spasticity, an increase in muscle tone leading to stiffness and involuntary muscle spasms, is a prevalent and often debilitating symptom in multiple sclerosis. It results from damage to the corticospinal tracts, which are descending motor pathways that normally inhibit muscle stretch reflexes. The loss of this inhibition leads to hyperexcitability of muscle stretch reflexes.
Choice E rationale
Vertigo, a sensation of spinning or dizziness, is a frequent complaint in multiple sclerosis. This symptom arises from demyelination and lesions affecting the brainstem or cerebellum, which are critical structures involved in maintaining balance and coordinating movement. Damage to these areas disrupts the processing of vestibular input, leading to disequilibrium and rotational sensations.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The humoral immune response is primarily mediated by B-lymphocytes, which differentiate into plasma cells to produce antibodies. T-lymphocytes, on the other hand, are central to cell-mediated immunity, directly destroying infected cells or coordinating other immune cells. These distinct lymphocyte populations have specialized roles in adaptive immunity.
Choice B rationale
Anaphylaxis is a severe, systemic hypersensitivity reaction that can be triggered by various allergens, including foods, insect venoms, medications, and blood products, not exclusively viral infections. While the immune system generally defends against pathogens, anaphylaxis represents an exaggerated and life-threatening response to otherwise harmless substances.
Choice C rationale
Anaphylaxis is primarily mediated by the rapid degranulation of mast cells and basophils, releasing potent inflammatory mediators like histamine and leukotrienes. Phagocytic natural killer cells are part of the innate immune system involved in direct cytotoxicity against virally infected cells and tumor cells, and they do not play a primary role in anaphylactic reactions.
Choice D rationale
Anaphylaxis following blood transfusion can occur when pre-existing antibodies in the recipient react with antigens in the transfused blood. In individuals with IgA deficiency, anti-IgA antibodies can form, leading to a severe anaphylactic reaction upon exposure to IgA in transfused blood products, causing mast cell degranulation.
Correct Answer is D
Explanation
Choice A rationale
Emotional disorders, such as depression or anxiety, can develop secondary to TBI due to changes in brain chemistry or damage to areas governing mood regulation. Acute pain can also be a consequence of the initial injury, but these are not the primary, overarching physiological or cognitive sequelae anticipated in the broad sense of secondary conditions.
Choice B rationale
Decreased appetite and sleep disturbances are common in TBI clients due to hypothalamic or brainstem injury, or medication side effects. While prevalent, they are specific symptoms rather than broad categories of secondary conditions that encompass a wider range of potential neurological deficits impacting daily function and long-term prognosis.
Choice C rationale
Body dysmorphia is a psychiatric disorder involving obsessive preoccupation with perceived flaws, unrelated to the direct neurological impact of TBI. Neurofibrillary tangles are microscopic protein aggregates associated with neurodegenerative diseases like Alzheimer's, not a direct or immediate secondary condition anticipated post-TBI, although TBI can increase long-term risk.
Choice D rationale
Loss of sensation, or sensory deficits, frequently occurs due to damage to somatosensory pathways in the brain or spinal cord. Cognitive difficulties, including problems with memory, attention, executive function, and information processing, are hallmark secondary conditions resulting from diffuse axonal injury or focal brain lesions following a traumatic brain injury.
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