Nokea
A nurse is assessing a client who has returned from a cerebral arteriogram. The left carotid site was punctured. Which of the following indicates complications?
- A. Difficulty swallowing (hematoma develops and pushes on the trachea)
- B. Puncture site is dry and red
- C. BP 120/82, HR 86, RR 22
- D. No swelling or hematoma at the site
Correct Answer: A
Rationale: Difficulty swallowing after a cerebral arteriogram may indicate a hematoma at the puncture site, which can compress the trachea and cause respiratory distress. This is a serious complication requiring immediate intervention to prevent airway obstruction and further complications.
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The effect of calcium ions on neurotransmitter release at synapses include:
- A. vesicular fusion
- B. tonic depolarization of the presynaptic neurone
- C. post-tetanic potentiation
- D. all above
Correct Answer: D
Rationale: Calcium ions trigger vesicular fusion, contribute to post-tetanic potentiation, and can cause tonic depolarization in the presynaptic neuron. These effects are essential for synaptic plasticity and neurotransmission.
True statements about the aqueous include:
- A. the production is about 2 ul/min
- B. the endothelium contribute to the production of aqueous
- C. its production decreases with age
- D. all above
Correct Answer: D
Rationale: Aqueous humor is produced at a rate of about 2 µL/min, primarily by the ciliary epithelium. The endothelium does not contribute to its production. Aqueous production decreases with age, which can affect intraocular pressure regulation.
A patient exhibits muscle weakness and loss of coordination. The nurse should:
- A. Perform a comprehensive neurologic assessment to identify the underlying cause.
- B. Measure the patient's blood pressure.
- C. Inspect the patient's skin for rashes.
- D. Check the patient's blood glucose levels.
Correct Answer: A
Rationale: Muscle weakness and loss of coordination require a comprehensive neurologic assessment to identify the cause. Blood pressure, skin rashes, and blood glucose levels are secondary considerations.
What is a nursing intervention that is appropriate for the patient with a nursing diagnosis of anxiety related to lack of knowledge of the etiology and treatment of headache?
- A. Help the patient to examine lifestyle patterns and precipitating factors.
- B. Administer medications as ordered to relieve pain and promote relaxation.
- C. Provide a quiet
- D. dimly lit environment to reduce stimuli that increase muscle tension and anxiety.
Correct Answer: C
Rationale: Reducing stimuli in the environment helps alleviate anxiety and muscle tension
The nurse is preparing to discharge a patient with chronic low back pain. Which statement by the patient indicates that additional teaching is necessary?
- A. I will avoid exercise because the pain gets worse.
- B. I will use heat or ice to help control the pain.
- C. I will not wear high-heeled shoes at home or work.
- D. I will purchase a firm mattress to replace my old one.
Correct Answer: A
Rationale: Avoiding exercise can lead to muscle weakness and worsening of back pain; exercise is often recommended as part of the treatment plan.