A nurse is caring for a client who has multiple sclerosis.
Which of the following assessment findings should the nurse anticipate? (Select all that apply)
Paresthesia.
Nausea and vomiting.
Dysphagia.
Spasticity.
Vertigo.
Correct Answer : A,C,D,E
Choice A rationale
Paresthesia, characterized by abnormal sensations such as tingling, numbness, or "pins and needles," is a common symptom in multiple sclerosis. This occurs due to demyelination and subsequent damage to sensory nerve pathways in the central nervous system, disrupting the normal transmission of sensory signals from the periphery to the brain. These sensory disturbances can fluctuate in intensity and location.
Choice B rationale
Nausea and vomiting are generally not considered primary or common assessment findings directly related to the pathophysiology of multiple sclerosis. While a client with MS might experience nausea and vomiting due to other co-existing conditions, medication side effects, or central nervous system lesions affecting areas involved in emesis (e.g., area postrema), it is not a hallmark symptom of the disease itself.
Choice C rationale
Dysphagia, or difficulty swallowing, is a significant symptom in multiple sclerosis, especially as the disease progresses. Demyelination and lesions in the brainstem or cranial nerves responsible for coordinating the complex muscular movements of swallowing can impair the pharyngeal and esophageal phases, increasing the risk of aspiration and nutritional deficiencies.
Choice D rationale
Spasticity, an increase in muscle tone leading to stiffness and involuntary muscle spasms, is a prevalent and often debilitating symptom in multiple sclerosis. It results from damage to the corticospinal tracts, which are descending motor pathways that normally inhibit muscle stretch reflexes. The loss of this inhibition leads to hyperexcitability of muscle stretch reflexes.
Choice E rationale
Vertigo, a sensation of spinning or dizziness, is a frequent complaint in multiple sclerosis. This symptom arises from demyelination and lesions affecting the brainstem or cerebellum, which are critical structures involved in maintaining balance and coordinating movement. Damage to these areas disrupts the processing of vestibular input, leading to disequilibrium and rotational sensations.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Disseminated intravascular coagulation (DIC) is characterized by widespread activation of the coagulation cascade, leading to the consumption of platelets and clotting factors, not an increase in platelet production. The body attempts to compensate, but consumption outpaces production, resulting in thrombocytopenia. Normal platelet count is 150,000 to 450,000 platelets per microliter.
Choice B rationale
DIC is pathologically defined by simultaneous excessive thrombosis and bleeding. Initial widespread microvascular clotting consumes platelets and coagulation factors, leading to tissue ischemia. Subsequent depletion of these crucial components results in paradoxical, severe bleeding from various sites, a hallmark of the disorder.
Choice C rationale
In DIC, clotting factors are consumed rapidly in the widespread microthrombotic process, leading to their significant decrease, not an increase. This depletion is a primary reason for the hemorrhagic manifestations seen in the later stages of the condition. Normal prothrombin time (PT) is 11-13.5 seconds, and activated partial thromboplastin time (aPTT) is 25-35 seconds.
Choice D rationale
Immediate sodium and fluid retention are not primary expected findings in DIC. While some fluid shifts can occur due to severe illness, the hallmark of DIC is a derangement of the coagulation system, not direct alterations in electrolyte balance or fluid volume regulation.
Correct Answer is A
Explanation
Choice A rationale
A traumatic brain injury (TBI) causes immediate disruption of cellular membranes and organelles, leading to neuronal dysfunction and cell death. Concurrently, blood vessels can be torn or compressed, resulting in hemorrhage (hematoma formation) and ischemia, both contributing to secondary brain injury and impaired neurological function.
Choice B rationale
Damage to brain tissue from a traumatic brain injury is related to *increased* pressure from the initial impact and subsequent edema and hemorrhage, not decreased pressure shock waves. The primary injury involves mechanical forces that directly deform and injure brain tissue and blood vessels, leading to increased intracranial pressure.
Choice C rationale
A traumatic brain injury typically leads to *decreased* synaptic connections due to neuronal damage and death, not increased connections. The disruption of neural pathways and loss of neurons impair communication within the brain, contributing to cognitive and functional deficits, rather than enhancing synaptic plasticity.
Choice D rationale
While there can be an initial increase in blood flow to the injured area due to autoregulatory mechanisms, the *consequence* of a traumatic brain injury is often disruption of blood supply (ischemia) and significant edema, which further compromises cerebral perfusion and neuronal viability. The increased blood supply is often a transient, ineffective response.
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