MS for Final Cunningham

The nurse is admitting a client diagnosed with multiple sclerosis. Which clinical manifestation should the nurse assess? Select all that apply. 1. Muscle flaccidity. 2. Lethargy. 3. Dysmetria. 4. Fatigue. 5. Dysphagia.

1,3,4,5 1.Muscle flaccidity is a hallmark symptom of MS. 3.Dysmetria is the inability to control muscular action characterized by overestimating or under estimating range of movement. 4.Fatigue is a symptom of MS. 5.Dysphagia, or difficulty swallowing, is associated with MS.

A nurse is caring for a client who is experiencing an acute exacerbation of MS. Which of the following actions should the nurse take? ​​​​​​​ Select all that apply. A Assist with ambulation 6 times daily. B Monitor for dysphagia. C Check skin integrity. D Use a communication board. E Encourage fluid intake.

BCDE from ati ebook

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? A. Fluctuations in blood pressure B. Loss of cognitive function C. Ineffective cough D. Drooping eye lids

CORRECT B: Loss of cognitive function is a manifestation associated with MS A. Fluctuations in blood pressure is a manifestation associated with amyotrophic lateral sclerosis.. C. Ineffective cough is a manifestation associated with amyotrophic lateral sclerosis. D. Drooping eyelids is a manifestation associated with myasthenia gravis.

A nurse is preparing to collect data for a client who has multiple sclerosis (MS). Which of the following findings should the nurse expect? A Elevated BP B Client report of fatigue C Client report of rhinitis D Muscle rigidity

B from ati ebook

The nurse is assessing a 48-year-old client diagnosed with multiple sclerosis. Which clinical manifestation warrants immediate intervention? 1. The client has scanning speech and diplopia. 2. The client has dysarthria and scotomas. 3. The client has muscle weakness and spasticity. 4. The client has a congested cough and dysphagia.

4.Dysphagia is a common problem of clients diagnosed with multiple sclerosis,and this places the client at risk for aspiration pneumonia. Some clients diagnosed with multiple sclerosis eventually become immobile and are at risk for pneumonia. Rationale 1. These are clinical manifestations of multiple sclerosis and are expected. 2. These are expected clinical manifestations of multiple sclerosis. 3. These are expected clinical manifestations of multiple sclerosis.

The nurse is assessing a client with a tentative diagnosis of MS. Which assessment finding would the nurse identify as a characteristic of early signs of MS? A. Diplopia B. Resting tremor C. Flaccid Paralysis D. Unilateral neglect

A. Diplopia (double vision)

The nurse would expect to find which of the following symptoms when assessing a 38-year-old patient diagnosed with multiple sclerosis? A) Vision changes B) Absent deep tendon reflexes C) Tremors at rest D) Flaccid muscles

Ans: A Feedback: Vision changes, such as diplopia, nystagmus, and blurred vision are symptoms of multiple sclerosis. Deep tendon reflexes may be increased or hyperactive, not absent. Babinski's sign may be positive. Tremors at rest aren't characteristic of multiple sclerosis; however, intentional tremors, or those occurring with purposeful voluntary movement, are common in patients with multiple sclerosis. Affected muscles are spastic rather than flaccid

A client admitted with an exacerbation of multiple sclerosis is demonstrating frustration with eating because hand and arm spasms prevent the proper use of utensils. What should the nurse do to assist this client? A) Consult with Occupational Therapy regarding assistive devices for meals. B) Counsel the client to select finger foods for meals. C) Plan time to feed the client. D) Consult with Physical Therapy regarding hand and arm exercises.

Answer: A Explanation: A) Since the ability to feed oneself is essential to positive self-concept and self-esteem, the nurse should consult with Occupational Therapy for devices that the client can use to maintain independence at meal times. The nurse should not counsel the client to select finger foods for meals, or feed the client. This would not support the client's self-concept and self-esteem needs. Physical Therapy might be consulted for hand splints, but hand and arm exercises might not be beneficial for this client.

When developing a long term care plan for the client with multiple sclerosis, the nurse should teach the client to prevent: a) fluid overload. b) contractures. c) dry mouth. d) ascites.

B) contractures. Explanation: Typical complications of multiple sclerosis include contractures, decubitus ulcers, and respiratory infections. Nursing care should be directed toward the goal of preventing these complications.

A client with multiple sclerosis (MS) lives with her daughter and 3-year-old granddaughter. The daughter asks the nurse what she can do at home to help her mother. Which measure would be most beneficial? a) weekly visits by another person with MS b) regular exercise c) psychotherapy d) day care for the granddaughter

B) regular exercise Explanation: An individualized regular exercise program helps the client to relieve muscle spasms. The client can be trained to use unaffected muscles to promote coordination because MS is a progressive, debilitating condition. The data do not indicate that the client needs psychotherapy, day care for the granddaughter, or visits from other clients

A client has had MS for 15 years and has received various drug therapies.What is the primary reason why the nurse has found it difficult to evaluate the effectiveness of the drugs that the client has used? A. the client exhibits intolerance to the drugs B. The client experiences spontaneous remissions from time to time C. The client requires multiple drugs simultaneously D. The client endures long periods of exacerbation before the illness responds to a particular drug.

B. The client experiences spontaneous remissions from time to time

Which nursing interventions might need to be considered in a care plan for a client with advanced multiple sclerosis? Select all that apply. Obtain daily weights to monitor weight gain. Establish a voiding time schedule. Ensure access to a language board when communicating with the client. Encourage the client to walk with feet wide apart.

Establish a voiding time schedule. Ensure access to a language board when communicating with the client. Encourage the client to walk with feet wide apart.

Multiple sclerosis is an immune-mediated, progressive demyelinating disease of the peripheral or central nervous system

Multiple sclerosis is an immune-mediated, progressive demyelinating disease of the central nervous system

__________________ is an immune-mediated, progressive demyelinating disease of the central nervous system, not the peripheral nervous system

Multiple sclerosis is an immune-mediated, progressive demyelinating disease of the central nervous system, not the peripheral nervous system

myasthenia gravis (MG), multiple sclerosis (MS), or Guillain Barre (GB)? A progressive immune-related demyelination disease of the CNS

multiple sclerosis (MS)

myasthenia gravis (MG), multiple sclerosis (MS), or Guillain Barre (GB)? Characterized by relapses and exacerbations which are caused by anything that stresses the immune system

multiple sclerosis (MS)

Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence? a) Establish a regular voiding schedule. b) Insert an indwelling urinary catheter. c) Limit fluid intake to 1,000 mL/day. d) Administer prophylactic antibiotics, as prescribed.

A) Establish a regular voiding schedule. Explanation: Maintaining a regular voiding pattern is the most appropriate measure to help the client avoid urinary incontinence. Fluid intake is not related to incontinence. Incontinence is related to the strength of the detrusor and urethral sphincter muscles. Inserting an indwelling catheter would be a treatment of last resort because of the increased risk of infection. If catheterization is required, intermittent self-catheterization is preferred because of its lower risk of infection. Antibiotics do not influence urinary incontinence

A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is not appropriate? a) limiting fluid intake to 1,000 mL/day b) setting a regular time for elimination c) using an elevated toilet seat d) eating a diet high in fiber

A) limiting fluid intake to 1,000 mL/day Explanation: Limiting fluid intake is likely to aggravate rather than relieve symptoms when a bowel retraining program is being implemented. Furthermore, water imbalance, as well as electrolyte imbalance, tends to aggravate the signs and symptoms of MS. A diet high in fiber helps keep bowel movements regular. Setting a regular time each day for elimination helps train the body to maintain a schedule. Using an elevated toilet seat facilitates transfer of the client from the wheelchair to the toilet or from a standing to a sitting position

A nurse is caring for a client with multiple sclerosis. Client education about the disease process includes which of the following explanations about the cause of the disorder? a) Regulatory mechanisms fail to halt the immune response. b) The immune system recognizes one's own tissues as "self." c) Excess cytokines cause tissue damage. d) The immune system recognizes one's own tissues as "foreign."

ANS d) The immune system recognizes one's own tissues as "foreign." Explanation: The immune system's recognition of one's own tissues as "foreign" rather than self is the basis of many autoimmune disorders, including multiple scelrosis. When regulatory mechanisms fail to halt the immune response or excess cytokines are produced, pathology occurs (eg, allergies, hypersensitivity).

What basic information will the nurse caring for a patient recently diagnosed with multiple sclerosis (MS) provide to him? A) It is a degenerative disease of the nervous system. B) It usually occurs more frequently in men. C) It has an acute onset. D) It is caused by a bacterial infection.

Ans: A Feedback: Multiple sclerosis is a chronic, degenerative, progressive disease of the central nervous system (CNS) characterized by the occurrence of small patches of demyelination in the brain and spinal cord. The cause of MS is not known; it affects twice as many women as men.

A client with relapsing-remitting multiple sclerosis tells the nurse that even though the primary symptoms of exacerbation are leg spasms and blurred vision, the hardest part is trying to get through the day because of being so tired. Which diagnosis should the nurse identify as a priority for this client? A) Fatigue B) Disturbed Sensory Perception C) Impaired Physical Mobility D) Self-Care Deficit

Answer: A Explanation: A) The client states that the worst part of the disease exacerbation is being tired even though leg spasms and blurred vision are present. The nurse should identify the diagnosis of Fatigue as being a priority for this client. The diagnoses of Impaired Physical Mobility because of the leg spasms and Disturbed Sensory Perception because of the blurred vision are additional nursing diagnoses applicable for this client, but they are not the priority based on the client's statement. The client may or may not have a Self-Care Deficit.

A client diagnosed with multiple sclerosis has an acute onset of visual changes, fatigue, and leg weakness. The client says that the last time this happened, recovery occurred in a few weeks. Which classification of multiple sclerosis is the client experiencing? A) Progressive-relapsing B) Secondary-progressive C) Relapsing-remitting D) Primary-progressive

Answer: C Explanation: A) There are four classifications of multiple sclerosis. The client has an exacerbation of symptoms and has a history of full recovery. This is classified as relapsing-remitting and is the most common type. Primary-progressive is a steady worsening of the disease with occasional minor recovery. Secondary-progressive begins as relapsing-remitting but the disease becomes worse between exacerbations. Progressive-relapsing is rare, with the disease progressing from the onset with periods of exacerbation.

myasthenia gravis (MG), multiple sclerosis (MS), or Guillain Barre (GB)? Most medications for this condition, like interferons, try to control the immune system from attacking. The only medication that works on the nerves itself would be methylprednisone to reduce inflammation.

multiple sclerosis (MS)

myasthenia gravis (MG), multiple sclerosis (MS), or Guillain Barre (GB)? Symptoms include fatigue, weakness, numbness, difficulty in coordination, loss of balance, pain, and visual disturbances. They progress to incontinence and uncontrollable muscle spasms.

multiple sclerosis (MS)

myasthenia gravis (MG), multiple sclerosis (MS), or Guillain Barre (GB)? which is peripheral nervous system demyelination, which is central nervous system demyelination, and which does not involve demyelination

myasthenia gravis (MG)-does not involve demyelination, involves Acetylcholine at the neural junction multiple sclerosis (MS)-central nervous system demyelination Guillain Barre (GB)- peripheral nervous system demyelination