Nokea
A patient becomes startled when the alarm rings for a fire drill. After reassuring the patient that there is no danger, an assessment is completed. Which finding may be related to a sympathetic response?
- A. Wheezing
- B. Confusion
- C. Incontinence
- D. Diminished bowel sounds
Correct Answer: D
Rationale: A sympathetic response, or fight-or-flight reaction, includes decreased gastrointestinal activity, leading to diminished bowel sounds. Wheezing, confusion, and incontinence are not typical sympathetic responses. Understanding the autonomic nervous system helps explain physiological changes during stress.
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What nursing interventions are most critical for a client diagnosed with encephalitis?
- A. Evaluating the client's ventilation capacity and lung sounds frequently.
- B. Observing closely for signs of respiratory distress.
- C. Administering an indwelling urethral catheter.
- D. Monitoring vital signs and LOC frequently.
Correct Answer: B
Rationale: Respiratory distress is a potential complication requiring close monitoring.
A client with relapsing-remitting multiple sclerosis tells the nurse that even though the primary symptoms of exacerbation are leg spasms and blurred vision, the hardest part is trying to get through the day because of being so tired. Which diagnosis should the nurse identify as a priority for this client?
- A. Fatigue
- B. Disturbed Sensory Perception
- C. Impaired Physical Mobility
- D. Self-Care Deficit
Correct Answer: A
Rationale: Fatigue is one of the most debilitating symptoms of MS and significantly impacts the client's quality of life. Addressing fatigue should be a priority in the care plan.
What should be included in the management during the first 48 hours after an acute soft tissue injury of the ankle (select one that doesn't apply)?
- A. Use of elastic wrap
- B. Initial immobilization and rest
- C. Elevation of ankle above the heart
- D. Alternating the use of heat and cold
Correct Answer: D
Rationale: The initial management includes rest, ice, compression, and elevation (RICE) to reduce swelling and pain.
The x-ray shows that the patient's fracture is at the remodeling stage. What characteristics of the fracture healing process are happening at this stage (select one that doesn't apply)?
- A. Radiologic union
- B. Absorption of excess cells
- C. Return to preinjury strength and shape
- D. Semisolid blood clot at the ends of fragments
Correct Answer: D
Rationale: During the remodeling stage, radiologic union occurs, excess cells are absorbed, and the bone returns to its preinjury strength and shape.
For what purpose would the nurse use the Mini-Mental State Examination to evaluate a patient with cognitive impairment?
- A. It is a good tool to determine the etiology of dementia.
- B. It is a good tool to evaluate mood and thought processes.
- C. It can help to document the degree of cognitive impairment in delirium and dementia.
- D. It is useful for initial evaluation of mental status but additional tools are needed to evaluate changes in cognition over time.
Correct Answer: C
Rationale: The MMSE documents cognitive impairment in delirium and dementia