Nokea
A healthcare professional is reviewing a patient's medical record. The record indicates the patient has limited shoulder flexion on the left. Which plane of movement is limited?
- A. Horizontal
- B. Sagittal
- C. Frontal
- D. Vertical
Correct Answer: B
Rationale: The correct answer is 'Sagittal.' The sagittal plane divides the body into left and right halves, and movements in this plane involve flexion and extension. In this case, limited shoulder flexion on the left indicates a restriction in the forward and backward movement of the arm, which occurs in the sagittal plane. Choice A, 'Horizontal,' is incorrect as it refers to movements parallel to the ground. Choice C, 'Frontal,' is incorrect as it involves side-to-side movements. Choice D, 'Vertical,' is incorrect as it typically refers to up and down movements.
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Is head lag expected to be resolved by 4 months of age? Continuing head lag at 6 months of age may indicate?
- A. Dizziness and orthostatic hypotension.
- B. Nausea, vomiting, diarrhea, or constipation, and stomach cramps.
- C. Drowsiness, lethargy, and fatigue.
- D. Neuropathy and tingling in the extremities.
Correct Answer: B
Rationale: Head lag is a developmental milestone that should be resolved by 4 months of age. Continuing head lag at 6 months of age may indicate potential developmental delays or muscle weakness. The correct answer, 'Nausea, vomiting, diarrhea, or constipation, and stomach cramps,' reflects symptoms that could be associated with developmental delays or underlying health conditions. Dizziness and orthostatic hypotension (Choice A) are unlikely to be directly related to head lag. Choices C and D present symptoms that are unrelated to the issue of continued head lag at 6 months of age.
A nurse is assessing an 18-year-old female who has recently suffered a TBI. The nurse notes a slower pulse and impaired respiration. The nurse should report these findings immediately to the physician due to the possibility the patient is experiencing which of the following conditions?
- A. Increased intracranial pressure
- B. Increased function of cranial nerve X
- C. Sympathetic response to activity
- D. Meningitis
Correct Answer: A
Rationale: The nurse should report the slower pulse and impaired respiration to the physician immediately as they are indicative of increased intracranial pressure (ICP) following a traumatic brain injury (TBI). These signs suggest that there may be a rise in pressure within the skull, which can be a life-threatening condition requiring urgent intervention. Options B and C are unlikely in this scenario as they do not correlate with the symptoms presented. Meningitis (Option D) typically presents with different signs and symptoms, such as fever, headache, and neck stiffness, which are not described in the patient's case.
Which physiologic mechanism best describes the function of the sodium-potassium pump?
- A. active transport
- B. diffusion
- C. filtration
- D. osmosis
Correct Answer: A
Rationale: Active transport is the correct answer as it accurately describes the process involved in the sodium-potassium pump. The pump utilizes energy to move ions against their concentration gradient, maintaining cellular concentrations. Diffusion (choice B) is a passive process where substances move from an area of higher concentration to lower concentration. Filtration (choice C) involves the movement of solutes based on pressure gradients. Osmosis (choice D) is the movement of water across a semipermeable membrane.
A client newly diagnosed with Diabetes Mellitus needs education. Which of the following statements should the nurse include in this education?
- A. "You can eat anything you want, but avoid foods with sugar."?
- B. "You need to lose weight, so your diet must be controlled."?
- C. "You need a diet and exercise program."?
- D. "You must reduce salt, fat, and sugar intake in your diet."?
Correct Answer: C
Rationale: A client newly diagnosed with Diabetes Mellitus requires education on managing their condition. Choice C is the correct answer because it emphasizes the importance of a comprehensive approach involving both diet and exercise. This holistic approach is crucial in managing blood sugar levels and overall health for individuals with diabetes. Choice A is incorrect as it provides misleading information by suggesting that the client can eat anything as long as it doesn't contain sugar, which is not accurate for diabetes management. Choice B is not the best option as it focuses solely on weight loss rather than addressing the holistic needs of a diabetic individual. Choice D is incorrect as it suggests eliminating all salt, fat, and sugar, which is an extreme approach and not a realistic or balanced way to manage diabetes.
When assessing a client with early impairment of oxygen perfusion, such as a pulmonary embolus, the nurse should expect to find restlessness and which of the following symptoms?
- A. cool, clammy skin
- B. bradycardia
- C. tachycardia
- D. eupnea
Correct Answer: C
Rationale: When a client has early impairment of oxygen perfusion, such as in a pulmonary embolus, the nurse should expect to find restlessness, diaphoresis, tachycardia, and cool skin. Tachycardia is a compensatory mechanism to increase oxygen delivery to tissues. Cool, clammy skin (choice A) is more indicative of impaired oxygen perfusion compared to warm, dry skin. Bradycardia (choice B) is less likely to occur in the early stages and is more common in severe cases. Eupnea (choice D) refers to normal respirations in rate and depth, which may not be altered in early impairment of oxygen perfusion.