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A patient arrived in the ER with a head injury. She is unconscious. The physician and a fellow nurse are the only staff members near the patient. Her husband begins to criticize the attending physician and suggest that a different physician should care for this patient. What is the best response?
- A. Report the nurse to the attending physician.
- B. Call the nurse away from the patient and remind him that the patient can still hear even if unconscious.
- C. Ask the nurse why he has such feelings.
- D. Simply nod your head in agreement.
Correct Answer: B
Rationale: Unconscious patients can still perceive their surroundings; thus, maintaining professional communication is important.
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Often the first signs of neurological disorders are deficits in basic cognitive functions and also deficits in skills that involve problem-solving, planning and engaging in goal-directed behaviour. These types of functions are known as
- A. Directive functions
- B. Executive functions
- C. Management functions
- D. Slave functions
Correct Answer: B
Rationale: Executive functions are higher-order cognitive processes that enable individuals to plan, focus attention, remember instructions, and juggle multiple tasks successfully. These functions are primarily associated with the prefrontal cortex and are crucial for goal-directed behavior, problem-solving, and self-regulation. Deficits in executive functioning are often early indicators of neurological disorders, as they impact an individual's ability to manage daily activities and adapt to new situations.
To assess a patient's sensory function, the nurse should:
- A. Test light touch, pain, and temperature sensation in various areas of the body.
- B. Measure the patient's heart rate.
- C. Inspect the patient's skin for lesions.
- D. Check the patient's blood glucose levels.
Correct Answer: A
Rationale: Sensory function is assessed by testing light touch, pain, and temperature sensation. Heart rate, skin lesions, and blood glucose levels are unrelated to sensory testing.
What sign/symptom would NOT be associated with infant botulism?
- A. difficulty suckling
- B. limp body
- C. stiff neck
- D. weak cry
Correct Answer: C
Rationale: The correct answer is C: stiff neck. Infant botulism is characterized by muscle weakness, including difficulty suckling, a limp body, and a weak cry. A stiff neck is not typically associated with infant botulism. The toxin affects the nervous system, causing muscle paralysis, but does not typically lead to neck stiffness. Therefore, choice C is the correct answer. Choices A, B, and D are incorrect because they are all common signs and symptoms of infant botulism, reflecting the muscle weakness and paralysis caused by the toxin.
The nurse practitioner is evaluating a patient with cluster headaches who has been prescribed sumatriptan (Imitrex). Which finding indicates that the medication is working?
- A. Decreased symptoms
- B. Absence of headaches
- C. Improved neurological function
- D. Decreased frequency of headaches
Correct Answer: A
Rationale: The correct answer is A: Decreased symptoms. Sumatriptan works by constricting blood vessels in the brain, reducing inflammation and pain associated with cluster headaches. Therefore, a decrease in symptoms such as intensity of pain, duration of headache, and associated symptoms indicates that the medication is working effectively. Choices B, C, and D are incorrect as the absence of headaches may not be realistic, improved neurological function may not be directly related to the medication, and decreased frequency of headaches does not necessarily imply effectiveness in managing the current headache episode.
Which of the following nursing diagnoses pertains to a client with a neurological deficit in relation to his marriage?
- A. Risk for Disuse Syndrome related to musculoskeletal inactivity and neuromuscular impairment
- B. Total Urinary Incontinence or Urinary Retention related to effects of disease or injury to the nervous system or spinal cord nerves
- C. loss of bladder tone
- D. Impaired Physical Mobility related to muscle weakness and paralysis
Correct Answer: D
Rationale: Neurological deficits can affect sexual function, impacting relationships.