Multiple Sclerosis Red Star Q

A client complains of "eye problems" and generalized weakness that became markedly worse after using the hot tub. The nurse's best response is the following: "Was the weather the same each time you used the hot tub?" "You'll feel better after getting this off your mind." "Please be brief with your answers so I can get you through this." "Can you tell me more about the eye problems?"

"Can you tell me more about the eye problems?" Rationale: It is important to collect more data to meet the client's needs, but a picture of multiple sclerosis seems to be unfolding. Open-ended statements by the nurse will assist the client to answer more questions. The weather is unrelated to the symptoms. The other statements appear to be judgmental or to patronize the client.

Which instructions would the nurse give to a client with multiple sclerosis who is experiencing urinary retention? "Decrease your fluid intake to decrease urgency." "Catheterize your bladder according to the schedule we discussed." "Drink caffeinated beverages to promote the ability to form urine." "Run water whenever you experience difficulty initiating urination."

"Catheterize your bladder according to the schedule we discussed." Rationale: Urinary retention in the client with multiple sclerosis is a sequela of impaired conduction of nerves, enervating the bladder. Performing self-catheterization will drain the bladder and help prevent urinary tract infection. The client with multiple sclerosis is encouraged to increase fluids to prevent constipation. Because urinary retention is incomplete emptying of the bladder, neither running water nor caffeine would be useful.

Which nursing diagnosis would the nurse choose for a client with multiple sclerosis (MS), regardless of type or severity? Fatigue Acute pain Risk for aspiration Impaired gas exchange

Fatigue Rationale: Fatigue affects all clients with MS regardless of type or severity. The other nursing diagnoses are not appropriate for all types or in all phases of MS.

During a multiple sclerosis exacerbation, the nurse would teach clients that they are at risk for: Anorexia Injury A sore throat Constipation

Injury Rationale: During an exacerbation, the client with multiple sclerosis experiences visual disturbances and weakness, which puts them at risk for falls and subsequent injuries. Risks for sore throat, constipation, and anorexia are not particularly increased during exacerbation.

The nurse plans to teach a client with multiple sclerosis about which medication when ordered by the physician? Antihistamines Antibiotics Interferon Levodopa

Interferon Rationale: Interferon is used to reduce exacerbations in clients with MS and to enhance immune function. The other medications are not used in the treatment of MS.

A client with multiple sclerosis is in the clinic for a follow-up appointment to check progress. The nurse that is caring for a client with multiple sclerosis concludes that the plan of care needs goal revisions if: The client attends an MS support group. The client is disheveled and unkempt. The client performs self-catheterization. The client gains 3 pounds.

The client is disheveled and unkempt. Rationale: The client with MS experiences fatigue and is taught to plan self-care activities during peak levels of energy. The client who is unkempt is not performing self-care effectively and the nurse would revise the plan and goals. Gaining weight is not a priority with MS. Self-catheterization and participation in a support group are examples of goals that have been met by the client.

The client with multiple sclerosis has been placed on diazepam (Valium) to help reduce muscle spasms. The nurse teaches the family of the client to: Make sure the client does not suddenly stop the medication. Make sure the client takes the medication with food. Watch for respiratory distress. Be aware that the medication can cause diarrhea.

Watch for respiratory distress. Rationale: Valium is a central nervous system depressant and the client and family are taught to recognize signs of respiratory distress. The medication can be taken with or without food. Diazepam is more likely to cause constipation than diarrhea. There is no caution about stopping diazepam suddenly.