Nokea
A nurse is assessing a client on the musculoskeletal floor and identifies symptoms of weak pulses, dusky color in the ankles, and 3+ local edema. Which of the following does the nurse suspect to be an issue with this client?
- A. Problems with circulation
- B. Problems with sensation
- C. Problems with mobility
- D. Problems with pain
Correct Answer: A
Rationale: Weak pulses, dusky color, and edema strongly suggest circulatory issues.
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The posterior column transmits which of the following
- A. Afferent pain and temperature
- B. Afferent tendon stretch impulses
- C. Motor tracts
- D. ?
Correct Answer: B
Rationale: The posterior columns (fasciculus gracilis and cuneatus) transmit proprioceptive and fine touch sensations. These pathways are essential for coordination and balance.
Brown-Sequard syndrome develops with the following damage of the spinal cord:
- A. complete transversal
- B. anterior horns
- C. half transversal
- D. posterior horns
Correct Answer: C
Rationale: Half transversal is the correct answer because Brown-Sequard syndrome results from damage to one side of the spinal cord. This leads to ipsilateral motor paralysis and loss of proprioception, and contralateral loss of pain and temperature sensation due to the crossing of spinothalamic tract fibers.
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.
Which of the following describes the pathophysiology of Parkinson disease?
- A. Multiple foci of nerve degeneration throughout brain and spinal cord
- B. Decreased secretion of acetylcholine at myoneural junctions
- C. Atrophy of voluntary muscles
- D. Destruction of nerve cells of the basal ganglia of the brain
Correct Answer: D
Rationale: Parkinson's disease involves destruction of dopaminergic neurons in the basal ganglia.
The nurse positions a client who is being treated for a fracture. Why should care be taken to position the client's joints in an anatomic alignment?
- A. To prevent deep vein thrombosis
- B. To facilitate the lung expansion and prevent the pooling of secretions
- C. To prevent the escalation of the pain and swelling
- D. To prevent damage to the peripheral nerves and the blood vessels
Correct Answer: D
Rationale: Proper alignment prevents nerve and vascular damage.