Multiple Sclerosis (ATI) & Lupus
A nurse is beginning a physical assessment of a client who has a new diagnosis of MS. Which of the following findings should the nurse expect? A. areas of paresthesia B. involuntary eye movements C. alopecia D. increased salivation E. ataxia
A, B, & E -areas of paresthesia (areas of loss of skin sensation are a finding in a client who has MS) -Involuntary eye movements (Nystagmus is a finding in a client who has MS) -Ataxia (ataxia occurs in MS as muscle weakness develops and there is loss of coordination)
A nurse is reviewing the plan of care for a client who has systemic lupus erythematosus (SLE). The client reports fatigue, joint tenderness, swelling, and difficulty urinating. Which of the following lab findings should the nurse anticipate? (SATA) A. positive ANA titer B. Increased hemoglobin C. 2+ urine protein D. Increased serum C3 and C4 E. elevated BUN
A, C, & E A. Positive ANA titer (a positive antinuclear antibody titer is an expected finding in a client who has SLE) C. 2+ urine protein (Increased urine protein is an expected finding due to kidney injury as a result of SLE) E. Elevated BUN (elevated BUN is an expected finding due to kidney injury in a client who has SLE)
A nurse is caring for a client who has SLE and is experiencing an episode of Raynaud's phenomenon. Which of the following findings should the nurse anticipate? A. Swelling of joints of the fingers B. pallor of toes with cold exposure C. feet that become reddened with ambulation D. client report of intense feeling of heat in the fingers
B. Pallor of toes with cold exposure Rationale: Pallor of the extremities occurs in Raynaud's phenomenon in a client who has SLE and has been exposed to cold or stress
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
B. loss of cognitive function Rationale: Loss of cognitive function is a manifestation associated with MS
A nurse is teaching a client who has SLE about self-care. Which of the following statements by the client indicates an understanding of the teaching? A. "i should limit my time to 10 minutes in the tanning bed" B. "i will apply powder to any skin rash" C. "i should use a mild hair shampoo" D. "i will inspect my skin once a month for rashes"
C. "i should use a mild hair shampoo" Rationale: A client who has SLE should use a mild hair shampoo that does not irritate the scalp
A nurse is teaching a client who has MS and a new prescription for baclofen. Which of the following statements should the nurse include in the teaching? A. "this medication will help you with your tremors" B. "this medication will help you with your bladder function" C. "this medication may cause your skin to bruise easily" D. "this medication may cause your skin to appear yellow in color"
D. "this medication may cause your skin to appear yellow in color" Rationale: Dantrolene & tizanidine are antispasmodic medications that are given to clients who have MS to treat muscle spasms. An adverse effect of this medication is a yellow appearance of the skin, also known as jaundice. The nurse should instruct the client to monitor for this finding, as this can be an indication of impaired liver function.
A nurse is assessing a client who has a new diagnosis of SLE. Which of the following findings should the nurse expect? A. weight gain B. Petechiae on thighs C. Systolic murmur D. alopecia
D. Alopecia