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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Paraplegia: Paraplegia is the paralysis of the lower extremities and possibly the trunk, which can occur with a spinal cord injury at the level of the T2-T3 vertebrae.

B. Paresthesia: Paresthesia refers to abnormal sensations such as tingling or numbness and is not typically associated with a spinal cord injury at the T2-T3 level. It may occur with nerve damage but is not the primary disability anticipated in this scenario.

C. Quadriplegia: Quadriplegia, also known as tetraplegia, involves paralysis of all four limbs and the trunk. It is more commonly associated with injuries at higher levels of the spinal cord, such as cervical injuries.

D. Hemiplegia: Hemiplegia involves paralysis of one side of the body and is typically caused by a stroke or brain injury, not a spinal cord injury at the T2-T3 level.

A. Furnish restraints at the bedside. B. Keep an oxygen setup at the bedside. C. Place the bed in the lowest position. D. Provide a suction setup at the bedside. E. Elevate the side rails near the head when the client is in bed.

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

Explanation

A. Furnish restraints at the bedside: Restraints are not indicated for clients with seizure disorders. In fact, restraints can increase the risk of injury during a seizure and should be avoided.

B. Keep an oxygen setup at the bedside: Oxygen may be necessary to support the client's respiratory function during and after a seizure. Having an oxygen setup readily available can ensure prompt administration if needed.

C. Place the bed in the lowest position: Lowering the bed can help prevent injury if the client
falls out of bed during a seizure. However, it is not always feasible or necessary to lower the bed to the lowest position, especially if the client has mobility limitations or other considerations.

D. Provide a suction setup at the bedside: Suctioning may be necessary to clear the airway and prevent aspiration if the client experiences excessive oral secretions or vomiting during or after a seizure.

E. Elevate the side rails near the head when the client is in bed: Elevating the side rails near the head can help prevent injury if the client thrashes or moves unpredictably during a seizure. However, it is essential to ensure that the client's head and neck remain adequately supported and that the side rails do not restrict access to the client during a seizure.

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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)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?

Correct Answer is A

Explanation

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

Explanation

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A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate?