Nokea
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.
You may also like to solve these questions
What would be an abnormal finding when assessing cranial nerve III (Oculomotor nerve)?
- A. Pupil dilation or asymmetry.
- B. Constricted pupils.
- C. Equal and reactive pupils.
- D. Normal eye movement.
Correct Answer: A
Rationale: Pupil dilation or asymmetry indicates dysfunction of cranial nerve III (Oculomotor nerve). Constricted pupils, equal and reactive pupils, and normal eye movement are normal findings.
The following are found in higher concentration in the tear than in the serum:
- A. sodium
- B. potassium
- C. Ig G
- D. glucose
Correct Answer: B
Rationale: Tears have a higher concentration of potassium compared to serum. This is due to the active secretion of potassium ions by the lacrimal gland. Sodium, IgG, and glucose are typically found in lower concentrations in tears compared to serum.
Regarding parasympathetic nervous system
- A. Supply all viscera
- B. Have connector cells in brainstem and sacrum
- C. ?
- D. ?
Correct Answer: B
Rationale: The parasympathetic nervous system has connector cells in the brainstem (cranial nerves III, VII, IX, X) and the sacral spinal cord (S2-S4). It is responsible for rest-and-digest functions.
In teaching a community group the appropriate first aid care of burns, you show them a picture of a wound which is red, has several intact large blisters, one broken blister, and a lot of moisture present. You would expect them to recognize the depth of this burn as
- A. partial-thickness
- B. first-degree
- C. full-thickness
- D. third-degree
Correct Answer: A
Rationale: Partial-thickness burns involve the epidermis and part of the dermis, often presenting with blisters and moisture.
The nurse suspects that a patient will be diagnosed as being in a comatose state based upon the Glasgow Coma Scale score. What score does the patient need to have to be identified as comatose?
- A. 7
- B. 9
- C. 11
- D. 13
Correct Answer: A
Rationale: A GCS score of 7 or less indicates a comatose state, while a score of 15 indicates full alertness. Scores of 9, 11, and 13 suggest varying degrees of neurological impairment but not coma. Recognizing a comatose state is critical for patient management.