The nurse is assessing a patient who has been diagnosed with multiple sclerosis (MS).

Which of the following findings is most consistent with this condition?

Muscle atrophy and fasciculations.

Intention tremors and nystagmus.

Flaccid paralysis and areflexia.

Hyperactive reflexes and spasticity.

Answer and Explanation

The Correct Answer is B

Intention tremors and nystagmus. These are some of the common symptoms of multiple sclerosis (MS), a condition that affects the central nervous system and causes communication problems between the brain and the rest of the body. Intention tremors are involuntary shaking movements that occur when a person tries to perform a precise action, such as reaching for an object or writing. Nystagmus is a condition where the eyes make repetitive, uncontrolled movements, often resulting in reduced vision and depth perception.

Choice A is wrong because muscle atrophy and fasciculations are more typical of motor neuron diseases, such as amyotrophic lateral sclerosis (ALS), which affect the nerve cells that control voluntary muscle movements.

Choice C is wrong because flaccid paralysis and areflexia are signs of lower motor neuron lesions, which can be caused by spinal cord injuries, peripheral nerve disorders, or Guillain-Barré syndrome.

Choice D is wrong because hyperactive reflexes and spasticity are signs of upper motor neuron lesions, which can be caused by stroke, traumatic brain injury, or cerebral palsy.

Normal ranges for some of the symptoms mentioned are:.

• Intention tremors: none or minimal.

• Nystagmus: none or minimal.

• Muscle atrophy: none or minimal.

• Fasciculations: none or minimal.

• Flaccid paralysis: none or minimal.

• Areflexia: absent or reduced reflexes.

• Hyperactive reflexes: normal or slightly increased reflexes.

• Spasticity: normal or slightly increased muscle tone.

A. Muscle atrophy and fasciculations B.

Intention tremors and nystagmus C.

Flaccid paralysis and areflexia D.

Hyperactive reflexes and spasticity

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Correct Answer is B

Explanation

The correct answer is B.

The client needs assistance with two ADLs.This is because the Katz Index of Independence in Activities of Daily Living (ADLs) is a tool that measures the client’s ability to perform six basic ADLs independently: bathing, dressing, toileting, transferring, continence, and feeding.The score ranges from 0 to 6, with 6 indicating complete independence, 4 indicating moderate impairment, and 2 or less indicating severe dependence.The score is based on the number of ADLs that the client can perform without supervision, direction, personal assistance, or total care.

Therefore, a score of 4 out of 6 means that the client needs assistance with two ADLs.

Choice A is wrong because it implies that the client is independent in all ADLs, which would require a score of 6 out of 6.

Choice C is wrong because it implies that the client is dependent on others for all ADLs, which would require a score of 0 out of 6.

Choice D is wrong because it implies that the client has difficulty with four ADLs, which would require a score of 2 out of 6.

The normal range for the Katz Index of Independence in Activities of Daily Living (ADLs) depends on the setting and population of the client.For example, one study found that the average score for residents in skilled nursing facilities was 3.1 out of 6.Another study found that the hierarchy of difficulty of the six ADLs from least to greatest was: eating, maintaining continence, transferring, toileting, dressing, and bathing.

A. Decreased immune system function with aging. B. Lack of knowledge or awareness about STIs. C. Reduced use of condoms or other barrier methods. D. Increased number of sexual partners or casual encounters. E. Increased vaginal dryness or atrophy with menopause.

Correct Answer is ["A","B","C","D"]

Explanation

The correct answer isA, B, C and D.

These are all factors that can increase the risk of sexually transmitted infections (STIs) in older adult clients.

A. Decreased immune system function with aging.This can make older adults more susceptible to infections and less able to fight them off.

B. Lack of knowledge or awareness about STIs.

Older adults may not have received adequate education or information about STIs, their symptoms, prevention and treatment.They may also have misconceptions or stigma about STIs that prevent them from seeking help or testing.

C. Reduced use of condoms or other barrier methods.

Older adults may not perceive themselves as at risk of STIs or may not know how to use condoms correctly or consistently.They may also face barriers such as cost, availability, embarrassment or partner resistance to using condoms.

D. Increased number of sexual partners or casual encounters.

Older adults may have more opportunities for sexual activity due to factors such as divorce, widowhood, online dating, travel or retirement.They may also engage in sexual behaviors that expose them to multiple or unknown partners, such as sex work, drug use or group sex.

Choice E is wrong becauseincreased vaginal dryness or atrophy with menopauseis not a risk factor for STIs in older adult clients.

While this condition can cause discomfort, pain or bleeding during sexual intercourse, it does not increase the likelihood of acquiring or transmitting an STI.However, it may affect the quality of life and sexual satisfaction of older women and their partners, and may require medical attention or lubrication products.

: Johnson BK.

Sexually transmitted infections and older adults.J Gerontol Nurs 2013;39(11):53-60.: World Health Organization (WHO).

Sexually transmitted infections (STIs).2022 Aug 22.: Journal of Gerontological Nursing (JGN).

Sexually Transmitted Infections and Older Adults.

2013 Sep 18.

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The nurse is assessing a patient who has been diagnosed with multiple sclerosis (MS). Which of the following findings is most consistent with this condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the results of a functional status assessment for an older adult client using the Katz Index of Independence in Activities of Daily Living (ADLs). The nurse notes that the client scored 4 out of 6 on this tool. What does this score indicate?

Correct Answer is B

Explanation

A nurse is assessing the risk factors for sexually transmitted infections (STIs) in older adult clients. Which of the following factors should the nurse consider? (Select all that apply.).

Correct Answer is ["A","B","C","D"]

Explanation

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The nurse is assessing a patient who has been diagnosed with multiple sclerosis (MS).

Which of the following findings is most consistent with this condition?