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.
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D.
All of the above.
The nurse should ask all of these questions to assess the possible causes of the client’s condition.
Depression and social isolation in older adults can be triggered by various factors, such as:.
• Losses or changes in life, such as death of a spouse, retirement, relocation, or chronic illness.
• Lack of social support or contact with family, friends, or neighbors, which can lead to loneliness and reduced self-esteem.
• Decreased engagement or interest in activities or hobbies that provide meaning, pleasure, or stimulation, which can affect mood and cognitive function.
By asking these questions, the nurse can identify the specific factors that contribute to the client’s depression and social isolation, and provide appropriate interventions to address them.
For example, the nurse can:.
• Provide emotional support and empathy to the client and help them cope with their losses or changes.
• Encourage the client to maintain or increase their social interactions and connections with others who share similar interests or experiences.
• Assist the client to resume or find new activities or hobbies that suit their abilities and preferences, and provide positive feedback and reinforcement.
Correct Answer is D
Explanation
The correct answer is D.
All of the above.
This is because all of these findings indicate that the client has experienced an improvement in mood, energy, appetite, sleep, interest and participation in social activities and hobbies, which are common signs of depression recovery.
Choice A is wrong because it only covers some of the symptoms of depression, such as mood, energy, appetite and sleep, but not others, such as interest and participation in social activities and hobbies.
Choice B is wrong because it only measures the client’s depression level using standardized scales, such as the Geriatric Depression Scale (GDS) or the Patient Health Questionnaire (PHQ-9), but not their actual functioning and quality of life.
Choice C is wrong because it only reflects the client’s interest and participation in social activities and hobbies, which are important aspects of depression recovery, but not their mood, energy, appetite, sleep or depression level.
The GDS and the PHQ-9 are both valid and reliable tools for screening and measuring depression in older adults.
The GDS is a 15-item questionnaire that asks the client to answer yes or no to questions about their mood, satisfaction, hopelessness, helplessness, worthlessness, guilt, agitation, withdrawal and suicidal thoughts.
The PHQ-9 is a 9-item questionnaire that asks the client to rate how often they have experienced symptoms of depression in the past two weeks, such as depressed mood, anhedonia, insomnia or hypersomnia, fatigue, appetite or weight changes, concentration problems, feelings of worthlessness or guilt.
A. The client reports an improvement in mood, energy, appetite and sleep B.
The client scores lower on the Geriatric Depression Scale (GDS) or the Patient Health Questionnaire (PHQ-9) C.
The client shows more interest and participation in social activities and hobbies D.
All of the above
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
