Page 2025 - Saunders Comprehensive Review For NCLEX-RN

17. Encourage the client and family to contact available
community resources.
XI. Multiple Sclerosis
A. Description

1. A chronic, progressive, noncontagious,

degenerative disease of the CNS characterized by
demyelinization of the neurons.
2. It usually occurs between the ages of 20 and 40 years
and consists of periods of remissions and
exacerbations.
3. The causes are unknown, but the disease is thought to
be the result of an autoimmune response or viral
infection.
4. Precipitating factors include pregnancy, fatigue, stress,
infection, and trauma.
5. Electroencephalographic findings are abnormal.
6. Assessment of a lumbar puncture indicates an
increased gamma globulin level, but the serum
globulin level is normal.
B. Assessment
1. Fatigue and weakness
2. Ataxia and vertigo
3. Tremors and spasticity of the lower extremities
4. Paresthesias
5. Blurred vision, diplopia, and transient blindness
6. Nystagmus
7. Dysphasia
8. Decreased perception to pain, touch, and temperature
9. Bladder and bowel disturbances, including urgency,
frequency, retention, and incontinence
10. Abnormal reflexes, including hyperreflexia, absent
reflexes, and a positive Babinski’s reflex
11. Emotional changes such as apathy, euphoria,
irritability, and depression
12. Memory changes and confusion

C. Interventions

1. Provide energy conservation measures during
exacerbation.
2. Protect the client from injury by providing safety
measures.
3. Place an eye patch on the eye for diplopia.
4. Monitor for potential complications such as urinary
tract infections, calculi, pressure ulcers, respiratory
tract infections, and contractures.
5. Promote regular elimination by bladder and bowel

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