When obtaining a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS), the nurse should

Assess for the presence of chest pain

Inspect the skin for rashes or discoloration

Ask the patient about any increase in libido.

Inquire about urinary tract problems

Answer and Explanation

The Correct Answer is D

A: "Assess for the presence of chest pain." While chest pain is an important symptom to evaluate in many patients, it is not specifically related to multiple sclerosis (MS). MS primarily affects the central nervous system and may not directly cause chest pain, making this assessment less relevant in the context of suspected MS.
B: "Inspect the skin for rashes or discoloration." Although skin changes can occur in various conditions, they are not characteristic of MS. MS primarily involves neurological symptoms, so inspecting the skin may not provide significant information regarding the patient's condition.
C: "Ask the patient about any increase in libido." Changes in libido are not typically associated with MS. Patients may experience various symptoms, including fatigue and mobility issues, but libido changes are not a primary concern or common symptom linked to the disease.
D: "Inquire about urinary tract problems." This is a relevant assessment for a patient with possible MS. Urinary dysfunction is common in individuals with MS due to neurological damage affecting bladder control. Patients may experience urgency, frequency, or incontinence, making it essential to assess urinary tract issues during the health history and physical examination. Addressing these concerns can help guide appropriate management strategies.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A: "Sumatriptan." Sumatriptan is a selective serotonin receptor agonist (triptan) used for the acute treatment of migraines. It acts by stimulating serotonin (5-HT) receptors in the brain, specifically the 5-HT_1B and 5-HT_1D subtypes. This action causes vasoconstriction of dilated intracranial blood vessels and inhibits the release of pro-inflammatory neuropeptides, effectively reducing headache pain and associated symptoms such as nausea and photophobia. Sumatriptan can be administered via oral, subcutaneous, or nasal spray routes and is generally well-tolerated, with a rapid onset of action.
B: "Atorvastatin." Atorvastatin is a lipid-lowering agent belonging to the statin class, primarily used to decrease low-density lipoprotein (LDL) cholesterol levels and reduce the risk of cardiovascular events. It functions by inhibiting HMG-CoA reductase, an enzyme involved in cholesterol biosynthesis in the liver. Atorvastatin does not have a role in migraine treatment and is not indicated for this purpose.
C: "Metformin." Metformin is an oral hypoglycemic agent used in the management of type 2 diabetes. It works by decreasing hepatic glucose production and improving insulin sensitivity in peripheral tissues. Metformin is not indicated for migraine treatment and has no known effect on migraine pathophysiology.
D: "Lisinopril." Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor used primarily for the management of hypertension and heart failure. It works by inhibiting the conversion of angiotensin I to angiotensin II, resulting in vasodilation and reduced blood pressure. While lisinopril may have some preventative effects for migraines in certain patients, it is not used for acute migraine treatment.

A. Whisper in one of the client's ears while occluding the other. B. Have the client identify specific smells. C. Ask the client to stick out their tongue and observe if it is midline. D. Observe for the ability of the client to turn their head side to side.

Correct Answer is C

Explanation

A. Whisper in one of the client's ears while occluding the other. This assesses cranial nerve VIII (vestibulocochlear nerve), which controls hearing and balance. It does not evaluate cranial nerve XII (hypoglossal nerve).
B. Have the client identify specific smells. This tests cranial nerve I (olfactory nerve), which is responsible for the sense of smell. Cranial nerve XII does not play a role in olfaction.
C. Ask the client to stick out their tongue and observe if it is midline. Cranial nerve XII (hypoglossal nerve) controls tongue movement. Asking the client to stick out their tongue and observing for deviation helps assess nerve function. A deviation to one side suggests nerve damage on that side. This nerve is essential for speech, swallowing, and controlling tongue position.
D. Observe for the ability of the client to turn their head side to side. This assesses cranial nerve XI (spinal accessory nerve), which controls the sternocleidomastoid and trapezius muscles. It does not assess cranial nerve XII, which is responsible for tongue movement.

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When obtaining a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS), the nurse should

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following is a commonly used medication for the acute treatment of migraines?

Correct Answer is A

Explanation

A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve XII?

Correct Answer is C

Explanation

A nurse is reviewing the medical record of a client who is experiencing delirium. Which of the following medications should the nurse identify as a cause of this disorder?

A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent a pulmonary embolism (PE)? (Select all that apply.)

Which type of headache would the nurse suspect when the headaches are unilateral and throbbing, preceded by a premonitory symptom of photophobia, and associated with a family history?

A nurse is caring for a patient that is experiencing status epilepticus. Which of the following prescribed medications should the nurse anticipate to administer?

After determining that the patient has a tension-type headache, which patient statement supports the nurse's finding?

A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care?

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?