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A nurse counseling a patient diagnosed with dissociative identity disorder (DID) should understand that the assessment of highest priority is:
- A. risk for self-harm
- B. cognitive functioning
- C. identification of drug abuse
- D. readiness to reestablish identity or memory
Correct Answer: A
Rationale: The correct answer is A: risk for self-harm. In patients with DID, the primary concern is ensuring their safety due to the high risk of self-harm or suicide. Assessing this risk is crucial for immediate intervention to prevent harm. Choice B, cognitive functioning, may be important but is secondary to ensuring patient safety. Choice C, identification of drug abuse, is relevant but not as urgent as addressing the risk for self-harm. Choice D, readiness to reestablish identity or memory, is important but not as critical as ensuring the patient's safety. Therefore, assessing the risk for self-harm takes precedence in the care of a patient with DID.
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To assess for a possible seizure disorder, the nurse should:
- A. Observe the patient for any involuntary movements or altered consciousness.
- B. Measure the patient's heart rate.
- C. Inspect the patient's skin for rashes.
- D. Check the patient's blood glucose levels.
Correct Answer: A
Rationale: Seizure disorders are assessed by observing for involuntary movements or altered consciousness. Heart rate, skin rashes, and blood glucose levels are unrelated to seizure assessment.
A patient has a severed spinal nerve as a result of trauma. Which statement is true in this situation?
- A. Because there are 31 pairs of spinal nerves, no effect results if only one nerve is severed.
- B. The dermatome served by this nerve will no longer experience any sensation.
- C. The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve.
- D. A severed spinal nerve will only affect motor function of the patient because spinal nerves have no sensory component.
Correct Answer: C
Rationale: Rationale for Correct Answer (C): When a spinal nerve is severed, adjacent spinal nerves can compensate and continue to carry sensations for the dermatome served by the severed nerve. This is possible due to the concept of dermatomes overlapping and the redundancy in sensory innervation. Therefore, the patient may still experience sensation in the affected area despite the specific nerve being severed.
Summary of Incorrect Choices:
A: Incorrect. Even if there are 31 pairs of spinal nerves, severing one nerve can still have a significant impact on sensory and motor functions depending on the location and severity of the injury.
B: Incorrect. Sensory loss would occur in the dermatome served by the severed nerve, but adjacent nerves can still carry sensations.
D: Incorrect. Spinal nerves have both sensory and motor components, so severing a spinal nerve can affect both sensory and motor functions, not just motor function.
When assessing a patient for signs of increased intracranial pressure (ICP), the nurse should look for:
- A. Changes in level of consciousness, headache, and vomiting.
- B. Normal pupil size and reaction.
- C. Absence of nausea or vomiting.
- D. Clear and coordinated movements.
Correct Answer: A
Rationale: Increased intracranial pressure (ICP) is associated with changes in consciousness, headache, and vomiting. Normal pupil size, absence of nausea, and clear movements are not indicative of ICP.
Mr. K., aged 60 years, has a diagnosis of transient ischemic attack. An essential aspect of his history that needs to be documented is
- A. sudden, brief loss of sensory, motor, or visual function
- B. determining if he has any allergies
- C. any history of neurologic disease
- D. his medication history, both prescribed and over-the-counter
Correct Answer: A
Rationale: Sudden neurological deficits are hallmark symptoms of TIA.
A patient recently started on phenytoin (Dilantin) to control simple complex seizures is seen in the outpatient clinic. Which information obtained during his chart review and assessment will be of greatest concern?
- A. The gums appear enlarged and inflamed.
- B. The white blood cell count is 2300/mm³.
- C. Patient occasionally forgets to take the phenytoin until after lunch.
- D. Patient wants to renew his driver's license in the next month.
Correct Answer: B
Rationale: A low white blood cell count could indicate bone marrow suppression, a serious side effect of phenytoin.