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A 28-year-old female patient has been diagnosed with occipital lobe damage after a car accident. What should the nurse expect the patient to need help with?
- A. Being able to feel heat
- B. Processing visual images
- C. Identifying smells appropriately
- D. Being able to say what she means
Correct Answer: B
Rationale: The occipital lobe is primarily responsible for processing visual images.
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Which of the following is a sign of urinary retention in older adults with neurologic deficit?
- A. Amnesia
- B. Hypotension
- C. Hypertension
- D. A behavior change
Correct Answer: D
Rationale: Behavior changes, such as confusion, can indicate urinary retention.
Which intervention should you delegate to the nursing assistant for a patient with carpal tunnel syndrome preparing for surgery?
- A. Initiate placement of a splint for immobilization during the day.
- B. Assess the patient's wrist and hand for discoloration and brittle nails.
- C. Assist the patient with daily self-care measures such as bathing and eating.
- D. Test the patient for painful tingling in the four digits of the hand.
Correct Answer: C
Rationale: Daily self-care assistance is a suitable task for a nursing assistant.
Priority Decision: A patient is admitted to the emergency department with a possible cervical spinal cord injury following an automobile crash. During admission of the patient, what is the highest priority for the nurse?
- A. Maintaining a patent airway
- B. Maintaining immobilization of the cervical spine
- C. Assessing the patient for head and other injuries
- D. Assessing the patient's motor and sensory function
Correct Answer: B
Rationale: Immobilization prevents further injury.
A patient is scheduled for a lumbar puncture. Which action should the nurse take when preparing this patient?
- A. Remove all metal jewelry.
- B. Administer enemas until clear.
- C. Remove the patient's dentures.
- D. Assist the patient into a side-lying position.
Correct Answer: D
Rationale: For a lumbar puncture, the patient is positioned in a side-lying or sitting position with the back flexed to widen the intervertebral spaces. Removing metal jewelry, administering enemas, or removing dentures are not necessary. Proper positioning ensures a successful procedure.
A patient recovering from an acute exacerbation of RA tells the nurse that she is too tired to bathe. What should the nurse do for this patient?
- A. Give the patient a bed bath to conserve her energy.
- B. Allow the patient a rest period before showering with the nurse's help.
- C. Tell the patient that she can skip bathing if she will walk in the hall later.
- D. Inform the patient that it is important for her to maintain self-care activities.
Correct Answer: A
Rationale: Conserving energy is critical during flares.