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 D

Explanation

A. Confusion: While confusion may occur in some neurological conditions, it is not directly associated with a positive Romberg test result.

B. Aphasia: Aphasia refers to difficulty with language and communication and is typically associated with brain injury or stroke, not with a positive Romberg test result.

C. Pain: Pain is not directly assessed by the Romberg test. However, a positive Romberg test result may indicate sensory ataxia, which can contribute to difficulty with proprioception and coordination, potentially leading to increased risk of injury and pain.

D. Falls: A positive Romberg test result indicates impaired proprioception and balance,
increasing the risk of falls, especially in older adults or individuals with neurological conditions. This is the expected problem associated with a positive Romberg test result.

A. A rising systolic blood pressure B. Change in mood or attention level C. Irregular respiratory rate and depth D. A bounding radial pulse

Correct Answer is B

Explanation

A. A rising systolic blood pressure: While increased intracranial pressure can lead to changes in blood pressure, it is not typically the first sign observed. Changes in blood pressure may occur later in the progression of increased intracranial pressure.

B. Change in mood or attention level: Changes in mood, behavior, or level of consciousness are often early signs of increased intracranial pressure. These changes may include irritability, confusion, restlessness, or lethargy.

C. Irregular respiratory rate and depth: Respiratory changes such as irregular breathing patterns or Cheyne-Stokes respirations can occur with increased intracranial pressure, but they are not typically the first sign observed.

D. A bounding radial pulse: While changes in pulse rate or quality may occur with increased
intracranial pressure, a bounding radial pulse is not typically the first sign observed. It may occur later in the progression of increased intracranial pressure as compensation mechanisms fail.

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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

Which problem should the nurse expect for a patient who has a positive Romberg test result?

Correct Answer is D

Explanation

When assessing the client with meningitis, the nurse looks for which manifestation as a frequent first sign of increased intracranial pressure?

Correct Answer is B

Explanation

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?

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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)?

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.)

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A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving a prescribed dose of aspirin?

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take?