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A patient is admitted to the medical unit with an exacerbation of multiple sclerosis. When assessing this patient, the nurse has the patient stick out her tongue and move it back and forth. What is the nurse assessing?
- A. Function of the hypoglossal nerve
- B. Function of the vagus nerve
- C. Function of the spinal nerve
- D. Function of the trochlear nerve
Correct Answer: A
Rationale: Tongue movement is controlled by the hypoglossal nerve (XII). The vagus nerve affects throat and voice, spinal nerves control body muscles, and the trochlear nerve moves the eye.
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The nurse is doing an initial assessment on a patient newly admitted to the unit with a diagnosis of cerebrovascular accident (CVA). The patient has difficulty copying a figure that the nurse has drawn and is diagnosed with visual-receptive aphasia. What brain region is primarily involved in this deficit?
- A. Temporal lobe
- B. Parietal-occipital area
- C. Inferior posterior frontal areas
- D. Posterior frontal area
Correct Answer: B
Rationale: Visual-receptive aphasia, involving difficulty copying figures, is linked to the parietal-occipital area, which integrates visual and spatial processing. Temporal lobe damage affects auditory comprehension, and frontal areas impact expressive speech.
A patient had a lumbar puncture performed at the outpatient clinic and the nurse has phoned the patient and family that evening. What does this phone call enable the nurse to determine?
- A. What are the patients and familys expectations of the test
- B. Whether the patients family had any questions about why the test was necessary
- C. Whether the patient has had any complications of the test
- D. Whether the patient understood accurately why the test was done
Correct Answer: C
Rationale: Post-lumbar puncture follow-up checks for complications like headaches or infection. Expectations and understanding should be addressed before the procedure.
A patient with lower back pain is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should prioritize what action?
- A. Positioning the patient with the head of the bed elevated 45 degrees
- B. Administering IV morphine sulfate to prevent headache
- C. Limiting fluids for the next 12 hours
- D. Helping the patient perform deep breathing and coughing exercises
Correct Answer: A
Rationale: Elevating the head 30-45 degrees post-myelography prevents contrast dye irritation in the brain, reducing headache risk. Fluids are encouraged, morphine is not standard, and breathing exercises are unnecessary.
A trauma patient in the ICU has been declared brain dead. What diagnostic test is used in making the determination of brain death?
- A. Magnetic resonance imaging (MRI)
- B. Electroencephalography (EEG)
- C. Electromyelography (EMG)
- D. Computed tomography (CT)
Correct Answer: B
Rationale: EEG confirms brain death by showing no electrical activity. MRI, CT, and EMG are not standard for this determination.
During the performance of the Romberg test, the nurse observes that the patient sways slightly. What is the nurses most appropriate action?
- A. Facilitate a referral to a neurologist.
- B. Reposition the patient supine to ensure safety.
- C. Document successful completion of the assessment.
- D. Follow up by having the patient perform the Rinne test.
Correct Answer: C
Rationale: Slight swaying during the Romberg test is normal and indicates successful completion. Significant swaying prompts further evaluation, but the Rinne test assesses hearing, not balance.