Nokea
A client who has been immobile from a neurological deficit is moved to another bed in the nursing home and, following the move, complains of pain in his leg. Which complication is possible?
- A. TIA's
- B. Paralysis
- C. Fractures
- D. Bruising
Correct Answer: C
Rationale: Immobilization increases the risk of fractures, especially in osteoporotic clients.
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Which number in the diagram corresponds to the renal pelvis? (Figure 2)
- A. 3
- B. 7
- C. 13
- D. 14
Correct Answer: C
Rationale: The number 13 corresponds to the renal pelvis because it is the funnel-shaped structure in the kidney that collects urine from the nephrons and channels it into the ureter. The renal pelvis is a critical part of the urinary system, as it serves as a reservoir for urine before it is excreted from the body.
The nurse will document which reflex is present when there is dorsiflexion of the great toe with fanning of other toes?
- A. Brudzinski
- B. Babinski (damage to the corticospinal tracts)
- C. Trousseaus
- D. Kernigs
Correct Answer: B
Rationale: The Babinski reflex, characterized by dorsiflexion of the great toe and fanning of the other toes, is abnormal in adults and indicates damage to the corticospinal tract. This reflex is normal in infants but disappears as the nervous system matures. Its presence in adults suggests neurological pathology.
The 'sodium-potassium pump' pumps ___________.
- A. sodium ions out and potassium ions in
- B. sodium ions in and potassium ions out
- C. sodium and potassium ions in
- D. sodium and potassium ions out
Correct Answer: A
Rationale: The sodium-potassium pump is a membrane protein that actively transports sodium ions out of the neuron and potassium ions into the neuron. This process requires energy in the form of ATP and helps maintain the resting membrane potential. By creating a concentration gradient of these ions, the pump ensures that the neuron is ready to generate action potentials and transmit nerve impulses efficiently.
A woman wears a size 7 shoe. She says, My feet are huge. I've asked three orthopedists to surgically reduce my feet. The patient tries to buy shoes to make her feet look smaller and, in social settings, conceals both feet under a table or chair. Which health problem is likely?
- A. Dissociative amnesia with fugue
- B. Illness anxiety disorder
- C. Body dysmorphic disorder
- D. Dissociative identity disorder
Correct Answer: C
Rationale: The correct answer is C: Body dysmorphic disorder. This disorder involves a preoccupation with perceived flaws in physical appearance that are not observable to others. In this case, the woman's belief that her feet are huge despite wearing a size 7 shoe indicates a distorted body image. She seeks surgical interventions and hides her feet, which are characteristic behaviors of individuals with body dysmorphic disorder.
A: Dissociative amnesia with fugue involves memory loss and wandering behavior, which are not exhibited in this scenario.
B: Illness anxiety disorder involves excessive worry about having a serious illness, which is not the focus of the woman's concern.
D: Dissociative identity disorder involves the presence of two or more distinct identities or personality states, which is not evident in this case.
A patient who had a below-the-knee amputation is to be fitted with a temporary prosthesis. It is most important for the nurse to teach the patient to do what?
- A. Inspect the residual limb daily for irritation.
- B. Apply an elastic shrinker before applying the prosthesis.
- C. Perform range-of-motion (ROM) exercises to the affected leg four times a day.
- D. Apply alcohol to the residual limb every morning and evening to toughen the skin.
Correct Answer: B
Rationale: Shrinkers help mold the residual limb for the prosthesis.