The nurse is reviewing the care plan of a client with Multiple Sclerosis. Which of the following nursing diagnoses should receive further validation? 1. Impaired mobility related to spasticity and fatigue. 2. Risk for falls related to muscle weakness and sensory loss. 3. Risk for seizures related t...
Nclex(MS) Stimulator Exam Questions
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The nurse is reviewing the care plan of a client with Multiple Sclerosis. Which of the following nursing
diagnoses should receive further validation? 1. Impaired mobility related to spasticity and fatigue. 2. Risk
for falls related to muscle weakness and sensory loss. 3. Risk for seizures related to muscle tremors and
loss of myelin. 4. Impaired skin integrity related bowel and bladder incontinence. - Answer 3
The nurse is teaching a client with bladder dysfunction from multiple sclerosis (MS) about bladder
training at home. Which instructions should the nurse include in the teaching plan? Select all that apply.
1. Restrict fluids to 1,000 mL/ 24 hours. 2. Drink 400 to 500 mL with each meal. 3. Drink fluids
midmorning, midafternoon, and late afternoon. 4. Attempt to void at least every 2 hours. 5. Use
intermittent catheterization as needed. - Answer 2,3,4,5
Which of the following is not a typical clinical manifestation of multiple sclerosis (MS)? 1. Double vision.
2. Sudden bursts of energy. 3. Weakness in the extremities. 4. Muscle tremors. - Answer 2
A client with multiple sclerosis (MS) is receiving baclofen (Lioresal). The nurse determines that the drug
is effective when it achieves which of the following? 1. Induces sleep. 2. Stimulates the client's appetite.
3. Relieves muscular spasticity. 4. Reduces the urine bacterial count. - Answer 3
A client has had multiple sclerosis (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? 1. The client exhibits intolerance to many drugs. 2. The client experiences spontaneous
remissions from time to time. 3. The client requires multiple drugs simultaneously. 4. The client endures
long periods of exacerbation before the illness responds to a particular drug. - Answer 2
When the nurse talks with a client with multiple sclerosis who has slurred speech, which nursing
intervention is contraindicated? 1. Encouraging the client to speak slowly. 2. Encouraging the client to
speak distinctly. 3. Asking the client to repeat indistinguishable words. 4. Asking the client to speak
louder when tired. - Answer 4
The right hand of a client with multiple sclerosis trembles severely whenever she attempts a voluntary
action. She spills her coffee twice at lunch and cannot get her dress fastened securely. Which is the best
legal documentation in nurses' notes of the chart for this client assessment? 1. "Has an intention tremor
, of the right hand." 2. "Right-hand tremor worsens with purposeful acts." 3. "Needs assistance with
dressing and eating due to severe trembling and clumsiness." 4. "Slight shaking of right hand increases to
severe tremor when client tries to button her clothes or drink from a cup." - Answer 4
A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining
program. Which strategy is inappropriate? 1. Eating a diet high in fiber. 2. Setting a regular time for
elimination. 3. Using an elevated toilet seat. 4. Limiting fluid intake to 1,000 mL/ day. - Answer 4
Which of the following is not a realistic outcome to establish with a client who has multiple sclerosis
(MS)? The client will: 1. Develop joint mobility. 2. Develop muscle strength. 3. Develop cognition. 4.
Develop mood elevation. - Answer 3
The nurse is preparing a client with multiple sclerosis (MS) for discharge from the hospital to home. The
nurse should tell the client: 1. "You will need to accept the necessity for a quiet and inactive lifestyle." 2.
"Keep active, use stress reduction strategies, and avoid fatigue." 3. "Follow good health habits to change
the course of the disease." 4. "Practice using the mechanical aids that you will need when future
disabilities arise." - Answer 2
Which of the following should the nurse include in the discharge plan for a client with multiple sclerosis
who has an impaired peripheral sensation? Select all that apply. 1. Carefully test the temperature of bath
water. 2. Avoid kitchen activities because of the risk of injury. 3. Avoid hot water bottles and heating
pads. 4. Inspect the skin daily for injury or pressure points. 5. Wear warm clothing when outside in cold
temperatures. - Answer 1,3,4,5
Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of
urinary incontinence? 1. Limit fluid intake to 1,000 mL/ day. 2. Insert an indwelling urinary catheter. 3.
Establish a regular voiding schedule. 4. Administer prophylactic antibiotics, as ordered. - Answer 3
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 of the following measures would be
most beneficial? 1. Psychotherapy. 2. Regular exercise. 3. Day care for the granddaughter. 4. Weekly visits
by another person with MS. - Answer 2
In a patient with MS, which of the following will the healthcare expect to identify? Select all that apply.
1) Flaccid paralysis
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