Nokea
A 22-year-old female patient recovering from a craniotomy begins crying and asking for her mother who is sleeping in the visitors' lounge. The patient's Glasgow Coma Scale (GCS) of 15 and pupils are equal and reactive. What nursing action would be most appropriate at this time?
- A. Ask the mother to come and stay with the patient.
- B. Administer an as-needed sedative to calm the patient.
- C. Notify the neurosurgeon that the patient is upset and crying.
- D. Reassure the patient, and sit with her until she falls back asleep.
Correct Answer: A
Rationale: The patient is stable with a GCS of 15 and normal pupillary response, indicating no immediate neurological concern. Emotional distress after surgery is common, and having a family member present can provide comfort. Sedation or notifying the surgeon is unnecessary unless there are signs of neurological deterioration.
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Bradycardia can occur in response to:
- A. elevated intraocular pressure
- B. ocular massage
- C. pulling of the extraocular muscle
- D. all above
Correct Answer: D
Rationale: Bradycardia can be triggered by elevated intraocular pressure, ocular massage, or extraocular muscle manipulation due to the oculocardiac reflex.
Any of the following cranial nerves has the parasympathetic nucleus EXCEPT:
- A. vagal
- B. oculomotor
- C. glossopharyngeal
- D. olfactory
Correct Answer: D
Rationale: Olfactory nerve is the correct answer because it is a sensory nerve responsible for the sense of smell and does not have a parasympathetic nucleus. In contrast, the vagus, oculomotor, and glossopharyngeal nerves all have parasympathetic components that regulate functions such as heart rate, pupil constriction, and salivation.
A 35 year-old reporter presents to your office for evaluation of back pain and weakness in his left leg. He was play-wrestling with his nephew and hurt his back 2 weeks ago. He states that he has noticed tingling in his left leg as well. He has not noticed incontinence of bowel or bladder function. You perform a physical examination and confirm that he is dragging his left foot when he walks and that his Achilles reflex is diminished. The diagnosis is a herniated disc. Which nerve root are you testing with the Achilles reflex?
- A. C5, C6
- B. L2, L3, L4
- C. S1, S2
- D. L4, L5
Correct Answer: C
Rationale: The Achilles reflex tests the S1 and S2 nerve roots. A diminished Achilles reflex may indicate a herniated disc compressing these nerve roots. C5, C6, L2, L3, L4, and L4, L5 are tested by other reflexes, such as the biceps, patellar, and brachioradialis reflexes.
Which of the following may reduce the risk of excessive bleeding in a client who is scheduled to undergo an orthopedic surgery?
- A. Withholding aspirin before the surgery.
- B. Withholding antacids before the surgery.
- C. Encouraging the intake of red meat before the surgery.
- D. Avoiding excess fluid intake before the surgery.
Correct Answer: A
Rationale: Aspirin can increase bleeding risk; withholding it reduces this risk.
An axon conducts nerve impulses _________ the cell body.
- A. away from
- B. toward
- C. both toward and away from
- D. around, bypassing
Correct Answer: A
Rationale: The axon is a long, slender projection of a neuron that conducts nerve impulses away from the cell body to other neurons, muscles, or glands. When an action potential is generated in the cell body, it travels along the axon to the axon terminals, where neurotransmitters are released into the synapse. This unidirectional flow ensures that signals are transmitted efficiently and accurately to their intended targets.