The nurse is assessing a patient who has been diagnosed with multiple sclerosis (MS).
Which of the following findings is most consistent with this condition?
Muscle atrophy and fasciculations.
Intention tremors and nystagmus.
Flaccid paralysis and areflexia.
Hyperactive reflexes and spasticity.
The Correct Answer is B
Intention tremors and nystagmus. These are some of the common symptoms of multiple sclerosis (MS), a condition that affects the central nervous system and causes communication problems between the brain and the rest of the body. Intention tremors are involuntary shaking movements that occur when a person tries to perform a precise action, such as reaching for an object or writing. Nystagmus is a condition where the eyes make repetitive, uncontrolled movements, often resulting in reduced vision and depth perception.
Choice A is wrong because muscle atrophy and fasciculations are more typical of motor neuron diseases, such as amyotrophic lateral sclerosis (ALS), which affect the nerve cells that control voluntary muscle movements.
Choice C is wrong because flaccid paralysis and areflexia are signs of lower motor neuron lesions, which can be caused by spinal cord injuries, peripheral nerve disorders, or Guillain-Barré syndrome.
Choice D is wrong because hyperactive reflexes and spasticity are signs of upper motor neuron lesions, which can be caused by stroke, traumatic brain injury, or cerebral palsy.
Normal ranges for some of the symptoms mentioned are:.
• Intention tremors: none or minimal.
• Nystagmus: none or minimal.
• Muscle atrophy: none or minimal.
• Fasciculations: none or minimal.
• Flaccid paralysis: none or minimal.
• Areflexia: absent or reduced reflexes.
• Hyperactive reflexes: normal or slightly increased reflexes.
• Spasticity: normal or slightly increased muscle tone.
A. Muscle atrophy and fasciculations B.
Intention tremors and nystagmus C.
Flaccid paralysis and areflexia D.
Hyperactive reflexes and spasticity
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D.
Decreased mental status.Dehydration in elderly people can cause confusion, disorientation, or drowsiness due to the loss of water and electrolytes from the body.
These symptoms can affect the cognitive function and alertness of the client.Dehydration can also lead to complications such as kidney problems, electrolyte imbalances, or low blood pressure.
Choice A is wrong because increased skin turgor is not a sign of dehydration.
Skin turgor is the ability of the skin to return to its normal shape after being pinched or pulled.Dehydration causes decreased skin turgor, meaning the skin stays tented or wrinkled after being pinched.
Choice B is wrong because decreased pulse rate is not a sign of dehydration.Dehydration causes increased pulse rate, as the heart has to work harder to pump blood to the vital organs when there is less fluid in the body.
Choice C is wrong because increased urine output is not a sign of dehydration.Dehydration causes decreased urine output, as the kidneys try to conserve water and produce more concentrated urine.
The urine may also be darker in color than normal.
Normal ranges for fluid intake and output vary depending on age, weight, activity level, and health status.
However, a general guideline is to drink at least eight 8-ounce glasses of water per day and produce at least 30 mL of urine per hour.
Correct Answer is D
Explanation
The correct answer is D.
Report any signs of infection or delayed wound healing.
This is because oral hypoglycemic agents lower the blood glucose level, but they do not prevent the complications of diabetes mellitus, such as impaired wound healing and increased susceptibility to infections.Therefore, the client should be advised to monitor for any signs of infection, such as fever, redness, swelling, or pus, and report them to the health care provider promptly.
Choice A is wrong because checking blood glucose levels at least four times a day is not necessary for most clients who are taking oral hypoglycemic agents.
The frequency of blood glucose monitoring depends on the type and dose of medication, the level of glycemic control, and the presence of other factors that may affect blood glucose, such as illness or stress.The client should follow the individualized plan prescribed by the health care provider regarding blood glucose monitoring.
Choice B is wrong because drinking plenty of fluids and avoiding caffeine is not specific to clients who are taking oral hypoglycemic agents.
This is a general recommendation for all clients who have diabetes mellitus, as dehydration and caffeine can worsen hyperglycemia and increase the risk of diabetic ketoacidosis or hyperosmolar hyperglycemic state.However, this alone is not sufficient to manage diabetes mellitus and prevent complications.
Choice C is wrong because eating small, frequent meals and avoiding simple sugars is also a general recommendation for all clients who have diabetes mellitus, as this can help to maintain a stable blood glucose level and prevent hypoglycemia or hyperglycemia.
However, this alone is not sufficient to manage diabetes mellitus and prevent complications.The client should also follow a balanced diet that includes complex carbohydrates, protein, fiber, and healthy fats, and consult with a dietitian or a diabetes educator for individualized dietary guidance.
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