Nokea
A 26 year-old man was in a motor vehicle accident and suffered a complete spinal cord injury to L3. The nurse assesses the patient for loss of motor function in the:
- A. Legs
- B. Abdomen
- C. Chest
- D. Arms
Correct Answer: A
Rationale: A spinal cord injury at the L3 level affects motor function in the legs. The abdomen, chest, and arms are controlled by higher spinal cord levels (thoracic and cervical). Loss of motor function in the legs is consistent with an L3 injury.
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The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure?
- A. Side-lying, with legs pulled up and head bent down onto the chest
- B. Side-lying, with a pillow under the hip
- C. Prone, in a slight Trendelenburg's position
- D. Prone, with a pillow under the abdomen
Correct Answer: A
Rationale: The side-lying position with legs pulled up and head bent down onto the chest is the standard position for a lumbar puncture. This position maximizes the space between the vertebrae, allowing easier access to the subarachnoid space for cerebrospinal fluid (CSF) collection. Proper positioning is critical to ensure the procedure is performed safely and effectively.
For a patient diagnosed with dissociative amnesia, complete this outcome: Within 4 weeks, the patient will demonstrate an ability to execute complex mental processes by:
- A. functioning independently.
- B. verbalizing feelings of safety.
- C. regularly attending diversional activities.
- D. describing previously forgotten experiences.
Correct Answer: D
Rationale: The correct answer is D because the patient diagnosed with dissociative amnesia typically struggles with memory loss. By describing previously forgotten experiences, the patient demonstrates progress in accessing and processing their memories. This indicates improvement in their ability to execute complex mental processes.
A - Functioning independently is too broad and does not directly address the cognitive aspect of dissociative amnesia.
B - Verbalizing feelings of safety focuses more on emotional regulation rather than cognitive abilities.
C - Regularly attending diversional activities may be beneficial for overall well-being but does not specifically target the core issue of memory impairment in dissociative amnesia.
In the spinal cord:
- A. Hemisection of the cord (Brown-Sequard Syndrome) results in paralysis and loss of touch and proprioception on the same side and loss of pain and temperature sensation on opposite side
- B. The cord ends at L3
- C. The lateral corticospinal tract is an important motor tract
- D. The blood supply at each level is in danger because of poor anastomoses
Correct Answer: A
Rationale: Brown-Sequard Syndrome involves ipsilateral motor and proprioceptive loss and contralateral pain/temperature loss due to hemisection of the spinal cord. This is due to the decussation of sensory pathways.
When assessing a patient's orientation, the nurse should:
- A. Ask the patient questions about their name, location, and the date.
- B. Measure the patient's temperature.
- C. Inspect the patient's skin color.
- D. Check the patient's pulse rate.
Correct Answer: A
Rationale: Orientation is assessed by asking the patient about their name, location, and the date. Temperature, skin color, and pulse rate are unrelated to orientation.
Which of the following is the correct sequence in a typical reflex arc:
- A. effector, afferent neuron, integration centre, efferent neuron, receptor
- B. receptor, afferent neuron, integration centre, efferent neuron, effector
- C. effector, efferent neuron, integration centre, afferent neuron, receptor
- D. receptor, efferent neuron, integration centre, afferent neuron, effector
Correct Answer: B
Rationale: The correct sequence in a reflex arc is: receptor detects the stimulus, afferent neuron transmits the signal to the integration center, efferent neuron carries the response signal, and effector produces the response. Therefore, B is the correct answer.