Nokea
The nurse is admitting a client diagnosed with multiple sclerosis. Which clinical manifestation should the nurse assess? Select all that apply.
- A. Muscle flaccidity.
- B. Lethargy.
- C. Dysmetria.
- D. Fatigue.
- E. Dysphagia.
Correct Answer: C,D,E
Rationale: MS causes dysmetria (impaired coordination), fatigue, and dysphagia due to neurological damage. Muscle flaccidity is atypical (spasticity is common), and lethargy is non-specific.
You may also like to solve these questions
Which sign/symptom should the nurse expect to assess in the client who is in the recovery stage of Guillain-Barré syndrome?
- A. Decreasing deep tendon reflexes.
- B. Drooping of the eyelids has resolved.
- C. A positive Babinski's reflex.
- D. Descending increase in muscle strength.
Correct Answer: D
Rationale: Recovery in Guillain-Barré syndrome shows descending muscle strength improvement. Reflexes improve, ptosis is unrelated, and Babinski’s is not typical.
The client diagnosed with multiple sclerosis is having trouble maintaining balance. Which intervention should the nurse discuss with the client?
- A. Discuss obtaining a motorized wheelchair for the client.
- B. Teach the client to stand with the feet slightly apart.
- C. Encourage the client to narrow his or her base of support.
- D. Explain the need to balance activity with rest.
Correct Answer: B
Rationale: Standing with feet apart widens the base of support, improving balance in MS. Wheelchairs are premature, narrowing support worsens balance, and rest is secondary.
The client on a medical floor is diagnosed with HIV encephalopathy. Which client problem is priority?
- A. Altered nutrition, less than body requirements.
- B. Anticipatory grieving.
- C. Knowledge deficit, procedures and prognosis.
- D. Risk for injury.
Correct Answer: D
Rationale: HIV encephalopathy increases confusion and motor deficits, making risk for injury the priority. Nutrition, grieving, and knowledge are secondary.
The client diagnosed with RA who has been prescribed etanercept, a tumor necrosis factor alpha inhibitor, shows marked improvement. Which instruction regarding the use of this medication should the nurse teach?
- A. Explain the medication loses its efficacy after a few months.
- B. Continue to have checkups and laboratory work while taking the medication.
- C. Have yearly magnetic resonance imaging to follow the progress.
- D. Discuss the drug is taken for three (3) weeks and then stopped for a week.
Correct Answer: B
Rationale: Regular checkups and lab work monitor for etanercept side effects (e.g., infection). Efficacy persists, MRI is not routine, and cycling is incorrect.
The client is diagnosed with myasthenia gravis. Which intervention should the nurse implement when administering the anticholinesterase pyridostigmine (Mestinon)?
- A. Administer the medication 30 minutes prior to meals.
- B. Instruct the client to take with eight (8) ounces of water.
- C. Explain the importance of sitting up for one (1) hour after taking medication.
- D. Assess the client's blood pressure prior to administering medication.
Correct Answer: A
Rationale: Administering pyridostigmine 30 minutes before meals maximizes muscle strength for swallowing. Water volume, sitting up, and BP checks are not specific requirements.