A nurse is conducting a problem-focused assessment for a client who reports nausea and vomiting. Which of the following statements should the nurse make to gather more information about the problem?

Choice A reason:

The client's level of fatigue and weakness is an important data to collect because fatigue is one of the most common and disabling symptoms of MS, affecting about 80% of people with the condition. Fatigue can interfere with the client's daily activities, quality of life, and ability to cope with other symptoms. Weakness is also a common symptom of MS, caused by damage to the nerve fibers that control muscle movements. Weakness can affect the client's mobility, balance, and coordination.

Choice B reason:

The client's cognitive and emotional status is another important data to collect because MS can affect the brain and spinal cord, leading to cognitive impairment in about 50% of people with MS. Cognitive impairment can affect the client's memory, attention, concentration, problem-solving, and decision-making skills. MS can also cause emotional changes, such as depression, anxiety, mood swings, irritability, and euphoria. Emotional changes can affect the client's coping skills, social relationships, and self-esteem.

Choice C reason:

The client's family history and genetic risk factors is not an important data to collect because MS is not a hereditary disease. Although genetic factors may play a role in increasing the susceptibility to MS, they are not sufficient to cause the disease by themselves. MS is thought to be caused by a combination of genetic and environmental factors that trigger an autoimmune response in the central nervous system. Therefore, knowing the client's family history and genetic risk factors will not help in diagnosing or managing MS.

Choice D reason:

The client's vision and hearing acuity is an important data to collect because MS can affect the optic nerve and cause visual disturbances, such as blurred vision, double vision, loss of color vision, pain in the eye, or temporary blindness. Visual disturbances are often the first symptom of MS and can recur or worsen over time. MS can also affect the auditory nerve and cause hearing problems, such as hearing loss, tinnitus, or vertigo. Hearing problems are less common than visual problems in MS but can still affect the client's communication and quality of life.

Choice E reason:

The client's mobility and coordination skills is an important data to collect because MS can damage the nerve fibers that control muscle movements and cause spasticity, tremors, ataxia, dysmetria, or dysdiadochokinesia. These symptoms can affect the client's mobility and coordination skills and increase the risk of falls, injuries, or disability. Assessing the client's mobility and coordination skills can help in planning interventions to improve function, safety, and independence.

Choice A reason:

The client will ambulate 50 feet with a walker by day 3. This is an example of a goal rather than an outcome because it is a specific action that the client intends to achieve within a certain time frame. It is also a process goal because it is a step or sub-goal towards a more significant and overarching goal, such as improving mobility or preventing complications. Process goals are more controllable and measurable than outcome goals.

Choice B reason:

The client will maintain fluid balance as evidenced by stable weight and urine output. This is an example of an outcome rather than a goal because it is the overarching result that the client intends to achieve. It is also an outcome goal because it enables the client to assess their present and intended performance results while developing an outline that guides the steps to realize it. Outcome goals are more general and less controllable than process goals.

Choice C reason:

The client will have improved gas exchange as indicated by oxygen saturation above 92%. This is an example of an outcome rather than a goal because it is the overarching result that the client intends to achieve. It is also an outcome goal because it enables the client to assess their present and intended performance results while developing an outline that guides the steps to realize it. Outcome goals are more general and less controllable than process goals.

Choice D reason:

The client will have normal bowel function. This is an example of an outcome rather than a goal because it is the overarching result that the client intends to achieve. It is also an outcome goal because it enables the client to assess their present and intended performance results while developing an outline that guides the steps to realize it. Outcome goals are more general and less controllable than process goals.