Difficulty: Medium
Average Score: 83%
Simulated
Passage / Scenario
A home care nurse is caring for a client who has advanced multiple.sclerosis.
Nurses' Notes.
2 weeks ago:Today: The client reports depression is increasing as they are unable to. participate in activities they once enjoyed because of the.
advancing multiple sclerosis.
Even getting up to the wheelchair.
is "just too much" for them.
The home health aide reported client will not permit turning. position changes.
The client states, "I can only get comfortable.
curled on my left side.
I'm not moving.". Vital Signs.
Today:Temperature 36.8┬░ C (98.2┬░ F). Heart rate 80/min.
Respiratory rate 20/min.
BP 116/76 mm Hg. Client Education.
1 week ago:Educated the client about the importance of getting out of bed.
changing positions in bed.
A home care nurse is caring for a client who has advanced multiple sclerosis. Select the 5 complications the client is at risk for.
Correct answer
A,E
Rationale
Immobility in advanced multiple sclerosis risks contractures from muscle tightening and urinary stasis from bladder pooling, increasing infection risk. Calcium resorption, hypocalcemia, and diarrhea are not directly related.