A nurse is assigned to take of a patient with multiple sclerosis. The priority nursing diagnosis for the pati… - NHM UP Staff Nurse-2021 Shift-1st

NHM UP Staff Nurse-2021 Shift-1st

Medical & Surgical Nursing

Medium

Appeared in: NHM UP Staff Nurse-2021 Shift-1st

Explanation

Multiple Sclerosis (MS) is a progressive demyelinating disease of the central nervous system, leading to hallmark symptoms like muscle weakness, spasticity, and ataxia.
These symptoms directly cause impaired physical mobility, which poses the most immediate and significant threat to the patient's safety due to a high risk of falls and injury.
Prioritizing mobility addresses a fundamental physiological and safety need according to Maslow's hierarchy, and helps prevent severe secondary complications like pressure ulcers, deep vein thrombosis (DVT), and respiratory infections.

Option A: While bladder dysfunction is very common in MS, it is not the highest priority. The immediate risk of physical injury from impaired mobility is a greater threat than urinary issues.
Option B: Altered body temperature is not a primary diagnosis for MS. While heat sensitivity (Uhthoff's phenomenon) can worsen symptoms, it is a factor to manage rather than the priority diagnosis itself.
Option C: Patient education is important, but it falls under psychosocial needs. According to Maslow's hierarchy, physiological and safety needs (like mobility) must be addressed before educational needs.

Clinical Relevance

Nursing practice connection: Safe nursing care depends on performing Prioritization of nursing diagnoses for Multiple Sclerosis (MS) in the correct sequence, documenting the action clearly, and monitoring for the expected response.
In managing chronic neurological conditions like MS, nurses must prioritize interventions based on patient safety. Impaired mobility directly correlates with fall risk, which is a leading cause of morbidity in this population.
A key nursing role is to anticipate and prevent secondary complications of immobility, such as pressure injuries and contractures, through proactive mobility plans and regular repositioning.
What if? If the patient was presenting with acute urinary retention and signs of a blocked catheter, 'Impaired urinary elimination' would temporarily become the immediate priority over mobility to prevent bladder damage and sepsis.

How to Approach the Question

First, identify the question type. This is a 'priority' question, which requires you to rank nursing diagnoses based on urgency and potential for harm.
Next, recall the pathophysiology of the disease mentioned: Multiple Sclerosis (MS). MS primarily affects motor and sensory nerve pathways.
Apply a framework like Maslow's hierarchy of needs or the ABCs (Airway, Breathing, Circulation). Here, Maslow's is most relevant. Safety and physiological needs are the base of the pyramid.
Evaluate each option against this framework. 'Impaired mobility' directly relates to patient safety (fall risk) and physiological integrity (risk of complications from immobility).
Compare the chosen priority to the other options. While urinary issues and knowledge deficits are valid concerns in MS, they do not pose the same immediate threat to life and safety as a fall or a DVT resulting from immobility.

Concept Tested & Keywords

Concept Tested: Prioritization of nursing diagnoses for Multiple Sclerosis (MS).
Stem keywords: multiple sclerosis, priority nursing diagnosis
Lead-in keywords: priority
Clinical cues: Patient with multiple sclerosis

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E6 Nursing Brunner Adult Health 3SA Vol 2 Part 2 p. 130-132

E6 Nursing Fundamentals Potter Perry 12e Part 4 p. 144-146