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  • Multiple Sclerosis
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  • Multiple Sclerosis

The nurse is assessing a client suspected of having multiple sclerosis. Which manifestation should the nurse expect to observe in the client? SATA A) Spastic movements B) Tachycardia C) Lack of coordination D) Decreased level of consciousness E) Double Vision - Answer A, C, E Rationale: ...

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  • 7 augustus 2024
  • 15
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  • Multiple Sclerosis
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Multiple Sclerosis Midterm Exam
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The nurse is assessing a client suspected of having multiple sclerosis. Which manifestation should the
nurse expect to observe in the client? SATA

A) Spastic movements

B) Tachycardia

C) Lack of coordination

D) Decreased level of consciousness

E) Double Vision - Answer A, C, E

Rationale:

Double vision is consistent with multiple sclerosis; multiple sclerosis (MS) causes demyelination and
plaque formation in the central nervous system, including damage to the optic nerve. Spastic
movements are consistent with MS because it is an upper motor neuron disorder; these disorders
involve the central nervous system and cause spasticity. Lack of coordination is consistent with multiple
sclerosis; coordination and balance are controlled in the cerebellum, and damage to nerve transmission
in the cerebellum can cause loss of coordination and poor balance. Decreased level of consciousness is
not a manifestation that is directly related to multiple sclerosis. Tachycardia, or rapid heart rate, is not a
manifestation of multiple sclerosis.



A client has been diagnosed with relapsing-remitting multiple sclerosis. Which statement by the nurse
most accurately explains to the client the onset of symptoms with this type of MS?

A) "Symptoms will become progressively worse with periods of flare-ups."

B) "Symptoms will not develop for at least several years after diagnosis."

C) "Symptoms will flare up at times, with periods of partial or complete remission."

D) "Symptoms will develop slowly, but continuously with no periods of remission." - Answer
C)"Symptoms will flare up at times, with periods of partial or complete remission."

Rationale:

A client with relapsing-remitting MS will experience periods of flare-ups followed by periods of partial or
complete remission. Clients experience slow but continuous worsening of disease with no remissions
with primary-progressive MS. Clients experience progressive worsening of the disease with periods of

, flare-ups with progressive-relapsing MS. Symptoms of MS typically develop immediately, not several
years after diagnosis.



The nurse is preparing to teach about the manifestations of MS to a client newly diagnosed with the
disease. Which manifestation should the nurse include in this teaching?

A) Hypertension

B) Difficulty chewing

C) Fever

D) Frequent dry cough - Answer B) Difficulty chewing

Rationale:

A common manifestation of MS is difficulty chewing; it should be included in client teaching. Frequent
dry cough, fever, and hypertension are not manifestation of MS.



A client presents with double vision and increasing weakness in the lower extremities. Which additional
information should lead the nurse to expect that diagnostic testing for MS will be ordered?

A) The client reports episodes of rapid heart rate during periods of weakness in the lower extremities.

B) The client reports increasing manifestation over the past week.

C) The client reports previous episodes, each lasting 1 day, and then no problems for at least 1 month.

D) The client reports pain in the lower back for the past few days. - Answer C) The client reports
previous episodes, each lasting 1 day, and then no problems for at least 1 month.

Rationale:

MS can cause episodes lasting for more than 24 hours, and the episodes occur more than 1 month apart.
1-week duration is too short to suspect multiple sclerosis; MS is diagnosed from manifestations that last
over a period of months; the client reports are not necessarily consistent with multiple sclerosis. MS
does not cause a rapid heart rate. The client could be describing a cardiac disorder that is causing
weakness from decreased cardiac output. Back pain for a few days is more consistent with a back injury.
The weakness in the legs could be from MS or from a back injury



The nurse is teaching a client diagnosed with MS about the factors that may precipitate a relapse. Which
factor should the nurse include? SATA

A) Increases in body temperature

B) Constipation

C) Stress

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