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A gerontologic nurse educator is providing practice guidelines to unlicensed care providers. Because reaction to painful stimuli is sometimes blunted in older adults, what must be used with caution?
- A. Hot or cold packs
- B. Analgesics
- C. Anti-inflammatory medications
- D. Whirlpool baths
Correct Answer: A
Rationale: Blunted pain response in older adults increases burn or frostbite risk from hot or cold packs. Medications and whirlpool baths are not directly related to this sensory change.
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The patient in the ED has just had a diagnostic lumbar puncture. To reduce the incidence of a postlumbar puncture headache, what is the nurses most appropriate action?
- A. Position the patient prone.
- B. Position the patient supine with the head of bed flat.
- C. Position the patient left side-lying.
- D. Administer acetaminophen as ordered.
Correct Answer: A
Rationale: Prone positioning after lumbar puncture minimizes cerebrospinal fluid leakage, reducing headache risk. Supine or side-lying positions are less effective, and acetaminophen is not a preventive measure.
The nurse educator is reviewing the assessment of cranial nerves. What should the educator identify as the specific instances when cranial nerves should be assessed? Select all that apply.
- A. When a neurogenic bladder develops
- B. When level of consciousness is decreased
- C. With brain stem pathology
- D. In the presence of peripheral nervous system disease
- E. When a spinal reflex is interrupted
Correct Answer: B,C,D
Rationale: Cranial nerve assessment is indicated for altered consciousness, brain stem issues, or peripheral nervous system disease. Neurogenic bladder and spinal reflexes involve spinal, not cranial, nerves.
A trauma patient in the ICU has been declared brain dead. What diagnostic test is used in making the determination of brain death?
- A. Magnetic resonance imaging (MRI)
- B. Electroencephalography (EEG)
- C. Electromyelography (EMG)
- D. Computed tomography (CT)
Correct Answer: B
Rationale: EEG confirms brain death by showing no electrical activity. MRI, CT, and EMG are not standard for this determination.
A patient is admitted to the medical unit with an exacerbation of multiple sclerosis. When assessing this patient, the nurse has the patient stick out her tongue and move it back and forth. What is the nurse assessing?
- A. Function of the hypoglossal nerve
- B. Function of the vagus nerve
- C. Function of the spinal nerve
- D. Function of the trochlear nerve
Correct Answer: A
Rationale: Tongue movement is controlled by the hypoglossal nerve (XII). The vagus nerve affects throat and voice, spinal nerves control body muscles, and the trochlear nerve moves the eye.
A patient had a lumbar puncture performed at the outpatient clinic and the nurse has phoned the patient and family that evening. What does this phone call enable the nurse to determine?
- A. What are the patients and familys expectations of the test
- B. Whether the patients family had any questions about why the test was necessary
- C. Whether the patient has had any complications of the test
- D. Whether the patient understood accurately why the test was done
Correct Answer: C
Rationale: Post-lumbar puncture follow-up checks for complications like headaches or infection. Expectations and understanding should be addressed before the procedure.