Nokea
A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse should identify that cranial nerve XI(11) is intact when the client performs which of the following actions?
- A. Shrugs his shoulders
- B. Smiles symmetrically
- C. Closes his eyes tightly
- D. Identifies a familiar scent
Correct Answer: A
Rationale: The correct answer is A: Shrugs his shoulders. Cranial nerve XI, also known as the accessory nerve, controls the movement of the trapezius and sternocleidomastoid muscles, which are responsible for shoulder shrugging. By asking the client to shrug his shoulders, the nurse can assess the integrity of cranial nerve XI.
Choices B, C, and D are incorrect because they are associated with other cranial nerves. Smiling symmetrically is controlled by cranial nerve VII (facial nerve), closing eyes tightly is controlled by cranial nerve V (trigeminal nerve), and identifying a familiar scent is related to cranial nerve I (olfactory nerve).
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Which of the following actions should the nurse take?
- A. Obtain the specimen immediately upon the client waking up.
- B. Wait 1 day to collect the specimen if the client cannot provide sputum.
- C. Ask the client to provide 15 to 20 ml of sputum in the container.
- D. Wear sterile gloves to collect specimen from the client.
Correct Answer: A
Rationale: The correct answer is A because obtaining the specimen immediately upon the client waking up is crucial for accurate results in sputum collection. In the morning, the sputum is usually more concentrated and provides a better sample. Waiting or collecting at other times may lead to diluted or contaminated samples, affecting test results. Choice B is incorrect as it suggests delaying collection, which could compromise the accuracy of the test. Choice C is incorrect because the amount specified is too high for sputum collection, risking contamination. Choice D is incorrect as sterile gloves are not always necessary for sputum collection, regular gloves are usually sufficient.
Which of the following actions should the nurse plan to take?
- A. Elevate the clients arm prior to insertion.
- B. Select a site on the client's dominant arm.
- C. Apply a tourniquet below the venipuncture site.
- D. Choose a vein that is palpable and straight.
Correct Answer: D
Rationale: The correct answer is D: Choose a vein that is palpable and straight. This is important because a palpable and straight vein ensures successful venipuncture and reduces the risk of complications such as infiltration or hematoma formation. Elevating the client's arm (A) may help visualize veins but does not guarantee choosing a suitable vein. Selecting a site on the client's dominant arm (B) is not necessary as both arms have suitable veins. Applying a tourniquet below the venipuncture site (C) can obstruct blood flow and distort the vein. Therefore, the best approach is to choose a vein that is palpable and straight for a successful venipuncture.
Which statement should the nurse make?
- A. Your desire to be an organ donor must be documented in writing
- B. You have the right to change your decision about organ donation at any time.
- C. Discussing your wishes with your family can help ensure they are honored.
- D. Organ donation does not delay funeral arrangements or affect body appearance.
- E. Medical care provided before death will not be affected by your organ donor status.
Correct Answer: E
Rationale: The correct answer is E because it addresses a common misconception. Organ donor status does not affect medical care provided before death. Choice A is incorrect as organ donor consent can also be verbal. Choice B is incorrect because changing one's decision about organ donation may not always be feasible in emergency situations. Choice C is incorrect as discussing wishes with family does not guarantee they will be honored legally. Choice D is incorrect as organ donation may have some impact on funeral arrangements and body appearance.
The nurse should identify the cardiac rhythm as which of the following?
- A. Ventricular asystole
- B. Second-degree heart block
- C. Sinus Tachycard
- D. Atrial fibrillation
Correct Answer: D
Rationale: The correct answer is D: Atrial fibrillation. In atrial fibrillation, the atria quiver instead of contracting effectively, leading to an irregular and rapid heart rate. This can be identified on an ECG by the absence of distinct P waves and irregular R-R intervals. Ventricular asystole (A) is the absence of ventricular contractions, second-degree heart block (B) is characterized by intermittent conduction block between the atria and ventricles, and sinus tachycardia (C) is a regular rapid heart rate originating from the sinus node.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing.
- A. Request a prescription for IV furosemide
- B. Implement rest. ice, elevation, compression (RICE)
- C. Check for pedal pulses and sans of ischemia
- D. Cellulitis
- E. Heart failure
- F. Muscle Strain
Correct Answer: C
Rationale: Unilateral swelling and warmth suggest deep vein thrombosis (DVT), requiring assessment for ischemia.