Mobility - Multiple Sclerosis
The nurse is performing a health history of a client diagnosed with multiple sclerosis (MS). Which data should the nurse gather? (Select all that apply.) A.Factors that affect symptoms B.Reflex assessment C.Cranial nerve assessment D.Exposure to environmental hazards E.Onset of symptoms
A.Factors that affect symptoms D.Exposure to environmental hazards E.Onset of symptoms Rationale: When performing a health history on a client with multiple sclerosis, the nurse needs to obtain information about factors that affect symptoms, onset of symptoms, and exposure to environmental hazards. Cranial nerve and reflex assessment are part of the physical examination.
The nurse is teaching a client diagnosed with multiple sclerosis (MS) about the factors that may precipitate a relapse. Which factor should the nurse include? (Select all that apply.) A.Increases in body temperature B.Acetaminophen use C.Fatigue D.Constipation E.Stress
A.Increases in body temperature C.Fatigue E.Stress Rationale: While there are no common triggers for relapses in MS, several factors such as stress, fatigue, and increases in body temperature may influence a relapse. MS may cause constipation; it is not a cause of a relapse. Acetaminophen may be used to reduce body temperature to prevent a relapse; however, it does not cause a relapse in symptoms.
The nurse evaluates the care of a client diagnosed with multiple sclerosis (MS). Which assessment should the nurse perform? (Select all that apply.) A.Need for assistive devices B.Bowel sounds C.The progression from relapsing-remitting MS to primary-progressive MS D.Presence of complications E.Emotional stability of the client
A.Need for assistive devices D.Presence of complications E.Emotional stability of the client Rationale: MS is an ever-changing disease that requires constant evaluation. The evaluation process should include the presence of complications such as infection because complications may lead to an exacerbation. The nurse should also evaluate the need for assistive devices and the emotional stability of the client because depression is common in clients with MS. Bowel sounds are not affected by MS. Relapsing-remitting MS may progress to secondary-progressive MS, not primary-progressive MS.
Which problem should the nurse include in the plan of care for a client with multiple sclerosis (MS)? (Select all that apply.) A.Risk of hopelessness B.Acute pain C.Risk of fatigue D.Altered urinary elimination patterns E.Impaired physical mobility
A.Risk of hopelessness C.Risk of fatigue D.Altered urinary elimination patterns E.Impaired physical mobility Rationale: When planning care for a client diagnosed with MS, the nurse needs to address the following problems: impaired physical mobility, risk of fatigue, altered urinary elimination patterns, and risk of hopelessness. Acute pain is not a problem that needs to be addressed when planning care for a client with MS.
Which goal is appropriate for the nurse to set for a client with multiple sclerosis (MS)? (Select all that apply.) A.The client will state methods to reduce urinary incontinence. B.The client will participate in an exercise program to maintain independence. C.The client will sleep 5 hours per night. D.The client will receive psychologic counseling as needed. E.The client will verbalize methods to prevent and treat diarrhea.
A.The client will state methods to reduce urinary incontinence. B.The client will participate in an exercise program to maintain independence. D.The client will receive psychologic counseling as needed. Rationale: Appropriate goals for the client with MS include participating in an exercise program to maintain independence, stating methods to reduce urinary incontinence, and receiving psychologic counseling as needed. Constipation, not diarrhea, is usually a problem for clients with MS. Because fatigue is also a problem, clients should receive at least 8 hours of sleep each night.
A client diagnosed with multiple sclerosis (MS) asks the nurse whether woodworking and carving objects can still be done as a hobby. Which response by the nurse is correct ? A.Having client remember and describe how all previous projects were assembled B.Advising client to increase intricate patterns of work C.Assisting client in identifying modifications that may be needed D.Telling client to continue to use all the woodworking tools as before
C.Assisting client in identifying modifications that may be needed Rationale: Continuing a long-standing hobby is possible. The client will need help to assist with some planned modifications. The visual blurring of MS combined with spasticity would make working on intricate patterns difficult. Short-term memory loss and difficulty with word finding may make remembering and describing previous projects difficult.
The nurse is preparing to teach about the manifestations of multiple sclerosis to a client newly diagnosed with the disease. Which manifestation should the nurse include in this teaching? A.Frequent dry cough B.Fever C.Difficulty chewing D.Hypertension
C.Difficulty chewing Rationale: A common manifestation of multiple sclerosis is difficulty chewing; it should be included in client teaching. Frequent dry cough, fever, and hypertension are not manifestations of multiple sclerosis.
The nurse caring for a client diagnosed with multiple sclerosis (MS) identifies a goal of promoting self-care. Which intervention should the nurse include? A.Teach the client to perform self-care activities at the end of the day. B.Teach the client to limit fluid intake. C.Encourage the client to wear arm or wrist braces. D.Encourage the client to take responsibility for all food preparation duties.
C.Encourage the client to wear arm or wrist braces. Rationale: Maintaining independence with self-care is important for the client with MS because it promotes a positive self-image and encourages participation in social activities. Encouraging the client to wear or use assistive devices as necessary promotes independence. Wearing arm or wrist braces provides stability during self-care activities. Self-care activities should be performed when energy levels are high, not at the end of the day when the client is fatigued. Receiving assistance with food preparation can promote independence with other activities of daily living (ADLs). Clients should consume adequate fluid intake, not limit fluids.
A client diagnosed with multiple sclerosis (MS) tells the nurse about exploring complementary health practices to help deal with the MS. Which health practice should concern the nurse most? A.Therapeutic horseback riding B.Acupuncture C.Low-dose naltrexone D.Bee venom therapy
D.Bee venom therapy Rationale: Bee venom therapy carries more risk (due to anaphylactic shock) to the client than benefit, so it is the therapy that most concerns the nurse. Therapeutic horseback riding and acupuncture have low risk and may be beneficial for some clients and for some symptoms. Low-dose naltrexone has been shown to improve quality of life, but has no impact on physical symptoms. It should not concern the nurse.
The nurse conducts discharge planning for a client diagnosed with multiple sclerosis (MS). Which intervention should the nurse include? (Select all that apply). A.Instruction for a low fat, low salt diet B.Teaching of good body mechanics C.Assessment of home safety D.Teaching of a bladder training program E.Arrangement for pastoral care consultation
B.Teaching of good body mechanics C.Assessment of home safety D.Teaching of a bladder training program Rationale: Before discharging a client diagnosed with MS, the nurse should conduct a home safety assessment to determine the client's ability to function safely at home and to evaluate the need for any assistance at home. The nurse should also teach the client the basics of good body mechanics to prevent injuries and a bladder-training program to help the client remain continent. Arranging for a pastoral care consult and instruction for a low fat, low salt diet are not appropriate interventions for a client diagnosed with MS.
The nurse is assessing a client suspected of having multiple sclerosis. Which manifestation should the nurse expect to observe in the client? (Select all that apply.) A.Spastic movements B.Decreased level of consciousness C.Tachycardia D.Lack of coordination E.Double vision
A.Spastic movements D.Lack of coordination E.Double vision Rationale: Double vision is consistent with multiple sclerosis; multiple sclerosis (MS) causes demyelination and plaque formation in the central nervous system, including damage to the optic nerve. Spastic movements are consistent with MS because it is an upper motor neuron disorder; these disorders involve the central nervous system and cause spasticity. Lack of coordination is consistent with multiple sclerosis; coordination and balance are controlled in the cerebellum, and damage to nerve transmission in the cerebellum can cause loss of coordination and poor balance. Decreased level of consciousness is not a manifestation that is directly related to multiple sclerosis. Tachycardia, or rapid heart rate, is not a manifestation of multiple sclerosis.
The nurse is planning care for a client diagnosed with multiple sclerosis (MS). Which collaborative service should be consulted to help maintain or improve the functional status of this client? (Select all that apply.) A.Vocational rehabilitation B.Pastoral care C.Cognitive therapy D.Occupational therapy E.Physical therapy
A.Vocational rehabilitation C.Cognitive therapy D.Occupational therapy E.Physical therapy Rationale: Vocational rehabilitation should be consulted because this service trains the client to use assistive devices. Physical therapy should be consulted because this service will help to maintain mobility and optimal functioning. Occupational therapy should be consulted because this service will enhance independence, productivity, safety, and retention of skills. Cognitive therapy should be consulted because this service will help to improve the client's ability to think, reason, concentrate, and remember. A pastoral care consultation will not help to improve the client's functional status.
The nurse performs an admission assessment on a client diagnosed with multiple sclerosis (MS). Which assessment should the nurse perform as a part of the physical examination? (Select all that apply.) A.The client's breathing sounds B.The client's speech C.The client's balance D.The client's affect E.The client's ability to hear
B.The client's speech C.The client's balance D.The client's affect Rationale: As part of the physical examination, the nurse should assess the client's balance, affect, and speech because these all may be affected by the disease. Breath sounds and the ability to hear are generally not affected by MS.
A client has been diagnosed with relapsing-remitting multiple sclerosis (MS). Which statement by the nurse most accurately explains to the client the onset of symptoms with this type of MS? A."Symptoms will not develop for at least several years after diagnosis." B."Symptoms will flare up at times, with periods of partial or complete remission." C."Symptoms will develop slowly, but continuously with no periods of remission." D."Symptoms will become progressively worse with periods of flare-ups."
B."Symptoms will flare up at times, with periods of partial or complete remission." Rationale: A client with relapsing-remitting MS will experience periods of flare-ups followed by periods of partial or complete remission. Clients experience slow but continuous worsening of disease with no remissions with primary-progressive MS. Clients experience progressive worsening of the disease with periods of flare-ups with progressive-relapsing MS. Symptoms of MS typically develop immediately, not several years after diagnosis.
A client diagnosed with multiple sclerosis (MS) is being treated with disease-modifying therapy. Which form of MS should the nurse suspect the client has? A.Progressive-relapsing MS B.Relapsing-remitting MS C.Secondary-progressive MS D.Primary-progressive MS
B.Relapsing-remitting MS Rationale: Disease-modifying therapies are not approved or used for the treatment of progressive forms of MS; they are only used for the relapsing-remitting form. Clients with progressive forms are treated with medications that are specific for their symptoms.
The nurse admits a client suspected of having multiple sclerosis (MS). Which diagnostic test should the nurse expect to be ordered? (Select all that apply.) A.Cystoscopy B.Electrocardiography C.Lumbar puncture D.Colonoscopy E.Magnetic resonance imaging (MRI)
C.Lumbar puncture E.Magnetic resonance imaging (MRI) Rationale: MRI and lumbar puncture are diagnostic tests that are useful in diagnosing MS. An MRI is used to detect the presence of lesions in the central nervous system (CNS) that indicate demyelination. A lumbar puncture is used to obtain cerebrospinal fluid (CSF), which is tested for the presence of substances that indicate the presence of MS. Electrocardiography, colonoscopy, and cystoscopy are not used to diagnose MS.
A client with multiple sclerosis reports difficulty walking. Which collaborative therapy should the nurse request? A.Occupational therapy B.Cognitive therapy C.Physical therapy D.Speech therapy
C.Physical therapy Rationale: Physical therapy helps clients with walking, strength, and balance issues. Occupational therapy enhances independence and activities dealing with activities of daily living (ADLs). Speech therapy is used for speech or swallowing problems. Cognitive therapy treats changes in the ability to think, reason, concentrate, and remember.
A client presents with double vision and increasing weakness in the lower extremities. Which additional information should lead the nurse to expect that diagnostic testing for multiple sclerosis (MS) will be ordered? A.The client reports episodes of rapid heart rate during periods of weakness in the lower extremities. B.The client reports pain in the lower back for the past few days. C.The client reports previous episodes, each lasting 1-day, and then no problems for at least 1 month. D.The client reports increasing manifestations over the past week.
C.The client reports previous episodes, each lasting 1-day, and then no problems for at least 1 month. Rationale: MS can cause episodes lasting for more than 24 hours, and the episodes occur more than 1 month apart. 1-week duration is too short to suspect multiple sclerosis; MS is diagnosed from manifestations that last over a period of months; the client reports are not necessarily consistent with multiple sclerosis. MS does not cause a rapid heart rate. The client could be describing a cardiac disorder that is causing weakness from decreased cardiac output. Back pain for a few days is more consistent with a back injury. The weakness in the legs could be from MS or from a back injury.
The nurse formulates the plan of care for a client diagnosed with multiple sclerosis (MS). The client stays up late at night, takes long hot showers, sleeps in a cool bedroom, loves fresh air all year round, and naps after lunch. Which lifestyle changes should the nurse suggest for the client? A.Eliminating the post-lunch nap B.Keeping night hours C.Turning the bedroom heat off and opening the windows D.Turning down the shower's temperature
D.Turning down the shower's temperature Rationale: Temperature extremes should be avoided by the client with MS, so the client should have a warm, not hot, shower. A heated bedroom with closed windows might help with MS symptoms. Rest is essential to fight fatigue, so the client should keep the post-lunch nap. Rather than continuing to keep night hours, the client might find that getting things done in the morning hours is easier.
A young woman with multiple sclerosis is planning to get pregnant. She asks the nurse, "What are the risks?" Which response by the nurse is correct? A."You should plan to have difficulty getting pregnant." B."You may have exacerbations during your last trimester." C."Pregnancy may cause your disease to progress faster." D."The drug treatment you are on may be harmful to the fetus."
D."The drug treatment you are on may be harmful to the fetus." Rationale: Pharmacologic treatment of MS involves drugs that may be harmful to a fetus. Evidence suggests that pregnancy does not influence the overall course of disease, and MS does not affect a woman's ability to become pregnant. Pregnant women are usually protected from exacerbations during the second and third trimester, but they have a 20-40% risk of developing a flare-up in the first 6 months postpartum.
