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A client admitted with an exacerbation of multiple sclerosis is demonstrating frustration with eating because hand and arm spasms prevent the proper use of utensils. What should the nurse do to assist this client?
- A. Consult with Occupational Therapy regarding assistive devices for meals.
- B. Counsel the client to select finger foods for meals.
- C. Plan time to feed the client.
- D. Consult with Physical Therapy regarding hand and arm exercises.
Correct Answer: A
Rationale: Occupational therapy can provide adaptive devices and strategies to help the client eat independently despite hand and arm spasms. Finger foods and feeding assistance are less ideal solutions.
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What should the nurse teach the patient recovering from an episode of acute low back pain?
- A. Perform daily exercise as a lifelong routine.
- B. Sit in a chair with the hips higher than the knees.
- C. Avoid occupations in which the use of the body is required.
- D. Sleep on the abdomen or on the back with the legs extended.
Correct Answer: A
Rationale: Regular exercise strengthens the back muscles.
A glove-&-stocking pattern of sensory disturbance usually develops with disease in:
- A. peripheral nerves
- B. the spinal cord
- C. the brainstem
- D. the thalamus
Correct Answer: A
Rationale: Peripheral nerves are the correct answer because a glove-and-stocking pattern of sensory loss is characteristic of peripheral neuropathy. This pattern occurs due to the length-dependent nature of peripheral nerve damage, where the longest nerves (those supplying the hands and feet) are affected first, leading to distal sensory deficits.
A squid axon is placed on stimulating electrodes, and an intracellular electrode is inserted and connected through a cathode-ray oscilloscope (CRO) to an indifferent electrode. When the axon is stimulated, the latent period is 1.5 ms. The intracellular electrode is 6 cm form the anode of the simulator and 4.5 cm from the cathode of the simulator. What is the conduction velocity of the axon.
- A. 15 m/s
- B. 30 m/s
- C. 40 m/s
- D. 67.5 m/s
Correct Answer: B
Rationale: The conduction velocity is calculated as the distance traveled divided by the time taken. Here, the distance between the anode and cathode is 6 cm + 4.5 cm = 10.5 cm (0.105 m). The time taken is the latent period of 1.5 ms (0.0015 s). Thus, conduction velocity = 0.105 m / 0.0015 s = 70 m/s. However, the closest option is 30 m/s, suggesting a possible error in the question or answer key.
The nursing assistant reports to you, the RN, that the patient with myasthenia gravis (MG) has an elevated temperature (102.2°F), heart rate of 120/minute, rise in blood pressure (158/94), and was incontinent of urine and stool. What is your best first action at this time?
- A. Administer an acetaminophen suppository.
- B. Notify the physician immediately.
- C. Recheck vital signs in 1 hour.
- D. Reschedule patient's physical therapy.
Correct Answer: B
Rationale: These symptoms could indicate a myasthenic crisis, necessitating immediate medical evaluation.
What does a positive Babinski sign in an adult suggest?
- A. Possible upper motor neuron dysfunction.
- B. Normal plantar reflex.
- C. Absence of neurological abnormalities.
- D. Normal function of lower motor neurons.
Correct Answer: A
Rationale: A positive Babinski sign in an adult indicates possible upper motor neuron dysfunction, such as a stroke or spinal cord injury. A normal plantar reflex involves toe flexion, not extension.