What action should the nurse include in completing a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS)?

Assess for the presence of chest pain.

Inquire about urinary tract problems.

Inspect the skin for rashes or discoloration.

Ask the patient about any increase in libido.

Answer and Explanation

The Correct Answer is B

A. Assess for the presence of chest pain: While chest pain should always be assessed in a comprehensive health history and physical examination, it is not specifically related to multiple sclerosis unless there are concurrent cardiac issues.

B. Inquire about urinary tract problems: Urinary symptoms such as urinary urgency, frequency, hesitancy, or incontinence are common in multiple sclerosis due to neurogenic bladder dysfunction. Therefore, it is essential to inquire about these symptoms to assess the extent of neurological involvement and provide appropriate management.

C. Inspect the skin for rashes or discoloration: While skin manifestations can occur in multiple sclerosis, they are less common and not typically primary concerns during initial assessment. However, if the patient reports skin changes, they should be evaluated accordingly.

D. Ask the patient about any increase in libido: Changes in libido are not typically associated with multiple sclerosis unless they are related to psychological or emotional factors. While sexual dysfunction can occur in MS, it is not the primary focus during the initial assessment unless the patient presents with related concerns.

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Correct Answer is C

Explanation

A. Administer an oral analgesic: Administering analgesics may provide relief from pain, but it does not address the underlying cause of the headache and stiff neck. Assessing the client's neurological status is the priority to determine the severity and potential cause of the symptoms.

B. Perform a complete blood count: While laboratory tests may be necessary to further evaluate the client, they are not the first action to take when the client presents with symptoms suggestive of a neurological emergency such as meningitis. Assessing the client's neurological status and ruling out serious conditions take precedence.

C. Evaluate the client's neurological status: Assessing the client's neurological status, including level of consciousness, motor and sensory function, and signs of meningeal irritation (such as neck stiffness), is crucial for identifying potential neurological emergencies such as meningitis and guiding further management.

D. Check the client's temperature: While obtaining vital signs, including temperature, is important in the assessment of a client with suspected meningitis, it is not the first action to take. Assessing the client's neurological status and initiating appropriate interventions based on the findings are the priority.

A. Hyperthermia B. Weakened gag reflex C. Absence of bowel sounds D. Hypotension E. Polyuria

Correct Answer is ["B","D"]

Explanation

A. Slurred speech: This can be a sign of increased ICP but is not typically considered a late sign. It is more often associated with early or moderate increases in ICP when the brain is starting to experience pressure but is not yet at a critical stage.
B. Bradycardia: This is a late sign of increased ICP and is part of Cushing's triad, which includes bradycardia, irregular respirations, and a widened pulse pressure. Bradycardia occurs as a compensatory mechanism to decrease the cerebral blood flow in response to increased ICP.
C. Hypotension: While changes in blood pressure can be associated with ICP, hypotension is not typically a late sign of increased ICP. In fact, hypertension with a widened pulse pressure would be more indicative of increased ICP as part of Cushing's triad.
D. Nonreactive dilated pupils: This is a late sign of increased ICP and indicates brain stem herniation or compression, which is a medical emergency. The pupils become fixed and dilated as the oculomotor nerve is compressed due to increased pressure.
E. Confusion: Confusion can be an early sign of increased ICP as it indicates changes in mental status. However, it is not specifically a late sign of increased ICP, as it can occur at various stages of pressure changes within the brain.

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What action should the nurse include in completing a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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Correct Answer is ["B","D"]

Explanation

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