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Practice Question

The nurse is assessing a patient with Multiple Sclerosis and notes the lower extremities of a patient have increased tone and resistance. How would the nurse document the finding?

Answer Choices:

Correct Answer:

Spasticity

Rationale:

🦵In Multiple Sclerosis, demyelination of central motor pathways (corticospinal tracts) causes upper motor neuron (UMN) signs, notably spasticityincreased tone and velocity-dependent resistance.

🦵Spasticity reflects loss of descending inhibitory control, leading to hyperexcitable stretch reflexes, clonus, and hyperreflexia in affected limbs.

🦵Clinically it manifests as stiffness, scissoring gait, and difficulty with rapid alternating movements, impacting mobility and safety.

🦵Management may include physical therapy, stretching, baclofen/tizanidine, and in refractory cases intrathecal baclofen or botulinum toxin.

🦵Accurate documentation of tone grade and functional impact informs rehabilitation goals and treatment response over time.

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This question is from ☑️ NR412-EXAM4 which contains 50 questions.

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Question Details
  • Category: RN Nursing Exam(s)
  • Subcategory: Examplify Exam(s)
  • Domain: Pathophysiology
  • Answer Choices: 4
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