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A client with multiple sclerosis is observed transferring from the bed to a motorized wheelchair and applying splints to the lower extremities before entering the bathroom to perform morning self-care. What could the nurse conclude regarding this observation?
- A. The client uses assistive devices to optimize autonomy.
- B. The client needs instruction to conduct morning care before applying splints to lower extremities.
- C. The client is dependent upon assistive devices.
- D. The client is reliant upon assistive devices for independent.
Correct Answer: A
Rationale: The client's use of assistive devices demonstrates their ability to maintain independence and adapt to their physical limitations.
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A 25 year-old housewife presents to the urgent care clinic for evaluation of paralysis in her face on the right side. She has a history of an upper respiratory infection 2 weeks before the onset of symptoms. She states that her face on the right is drooping and she is not able to close the right eye. On physical examination, you note that her forehead is smooth on the right, the left palpebral fissure appears wider than the right, and her nasolabial fold on the right is flattened and she is drooling. Based on this information, what is the most likely diagnosis?
- A. Cortical stroke
- B. Bell's palsy
- C. Horner's syndrome
- D. Stress reaction
Correct Answer: B
Rationale: Bell's palsy is a condition characterized by sudden, unilateral facial paralysis due to inflammation or compression of the facial nerve (CN VII). It often follows a viral infection and presents with drooping of the face, inability to close the eye, and flattening of the nasolabial fold. A cortical stroke typically spares the forehead, and Horner's syndrome involves ptosis and miosis.
The cerebellum, ________ portion of the brain, is located below the occipital lobes of the cerebrum.
- A. the largest
- B. the second largest
- C. the third largest
- D. the smallest
Correct Answer: B
Rationale: The cerebellum is the second largest portion of the brain, located below the occipital lobes of the cerebrum. It plays a crucial role in coordinating voluntary movements, balance, and posture. While the cerebrum is the largest part of the brain, the cerebellum is smaller but still significant in size and function. Therefore, the second largest is the correct answer.
An elderly patient presents with a right-sided headache and acute loss of vision on the same side. Tenderness is noted to the right temporal region as well as to the scalp. To obtain a definitive diagnosis, the nurse practitioner will order:
- A. Erythrocyte sedimentation rate (ESR)
- B. C-reactive protein (CRP)
- C. Temporal artery biopsy
- D. CT scan of the head
Correct Answer: C
Rationale: The correct answer is C: Temporal artery biopsy. This is the gold standard for diagnosing giant cell arteritis, which presents with symptoms such as headache, vision loss, and tenderness to the temporal region and scalp. The biopsy will show characteristic inflammatory changes in the artery wall.
A: ESR and B: CRP are nonspecific markers of inflammation and can be elevated in various conditions, including giant cell arteritis, but they do not provide a definitive diagnosis.
D: CT scan of the head may show signs of inflammation in the temporal artery, but it is less sensitive than a biopsy for diagnosing giant cell arteritis.
Proper body alignment of the hemiplegic patient with the use of a footboard, trochanter rolls, and pillows will minimize the development of
- A. plantar extension
- B. shoulder abduction
- C. internal hip rotation
- D. external hip rotation
Correct Answer: A
Rationale: Footboards prevent plantar extension deformities.
A person who experiences an aura as part of his/her seizure pattern should be instructed to
- A. lie down in a safe place
- B. take additional anticonvulsant medication
- C. call an ambulance
- D. exercise vigorously
Correct Answer: A
Rationale: Lying down in a safe place can prevent injury during a seizure.