What action should the nurse include in completing a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS)?
Assess for the presence of chest pain.
Inquire about urinary tract problems.
Inspect the skin for rashes or discoloration.
Ask the patient about any increase in libido.
The Correct Answer is B
A. Assess for the presence of chest pain: While chest pain should always be assessed in a comprehensive health history and physical examination, it is not specifically related to multiple sclerosis unless there are concurrent cardiac issues.
B. Inquire about urinary tract problems: Urinary symptoms such as urinary urgency, frequency, hesitancy, or incontinence are common in multiple sclerosis due to neurogenic bladder dysfunction. Therefore, it is essential to inquire about these symptoms to assess the extent of neurological involvement and provide appropriate management.
C. Inspect the skin for rashes or discoloration: While skin manifestations can occur in multiple sclerosis, they are less common and not typically primary concerns during initial assessment. However, if the patient reports skin changes, they should be evaluated accordingly.
D. Ask the patient about any increase in libido: Changes in libido are not typically associated with multiple sclerosis unless they are related to psychological or emotional factors. While sexual dysfunction can occur in MS, it is not the primary focus during the initial assessment unless the patient presents with related concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Start a labetalol drip to keep BP less than 140/90 mm Hg: This order is appropriate because it aims to lower the patient's blood pressure to a target range recommended for acute ischemic stroke management.
B. Keep the head of the bed elevated at least 30 degrees: This intervention is part of stroke management to prevent aspiration and improve cerebral perfusion.
C. Begin tissue plasminogen activator (tPA) intravenously per protocol: The nurse should question this order because tissue plasminogen activator (tPA) is contraindicated in patients with stroke who have had symptoms for more than 3 hours or have unknown time of onset, as in this case where the patient has been aphasic for 3 hours. Administering tPA in this situation could increase the risk of bleeding complications without providing benefit.
D. Infuse normal saline intravenously at 75 mL/hr: This order is appropriate for maintaining hydration and intravascular volume in the acute care setting.
Correct Answer is A
Explanation
A. The patient had a recent acute myocardial infarction: Sumatriptan is contraindicated in patients with a history of myocardial infarction or coronary artery disease due to its vasoconstrictive effects, which could exacerbate ischemia or precipitate cardiovascular events.
B. The patient has had migraine headaches for 30 years: While the duration of migraine headaches is relevant to the patient's history, it is not as immediately concerning as a recent myocardial infarction when considering the use of sumatriptan.
C. The patient drinks 1 to 2 cups of coffee daily: While caffeine consumption may interact with sumatriptan and affect its efficacy or side effects, it is not as immediately concerning as a recent myocardial infarction.
D. The patient has taken topiramate (Topamax) for 2 months: While the use of topiramate may interact with sumatriptan, it is not as immediately concerning as a recent myocardial infarction. However, it is still important to report all medications the patient is taking to the healthcare provider.
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