Nokea
A patient is admitted with an open fracture of the tibia following a bicycle accident. During assessment of the patient, what specifically should the nurse question the patient about?
- A. Any previous injuries to the leg
- B. The status of tetanus immunization
- C. The use of antibiotics in the last month
- D. Whether the injury was exposed to dirt or gravel
Correct Answer: B
Rationale: Tetanus prophylaxis is crucial in open fractures due to the risk of contamination.
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The ability that humans have to perform very skilled movements such as writing is controlled by the:
- A. Basal ganglia.
- B. Corticospinal tract.
- C. Spinothalamic tract.
- D. Extrapyramidal tract.
Correct Answer: B
Rationale: The correct answer is B: Corticospinal tract. The corticospinal tract is responsible for controlling voluntary skilled movements like writing. It carries motor commands from the primary motor cortex to the spinal cord, enabling precise movements of the hands and fingers. The basal ganglia (A) are involved in motor planning and coordination but not direct control of skilled movements. The spinothalamic tract (C) is responsible for transmitting sensory information related to pain and temperature, not motor control. The extrapyramidal tract (D) is involved in involuntary movements and posture regulation, not skilled movements like writing.
In efferent pupillary defect:
- A. anisocoria is present
- B. the damage may be in the visual cortex
- C. the damage may be in the superior colliculus
- D. all above
Correct Answer: D
Rationale: Efferent pupillary defect causes anisocoria and can result from damage to the visual cortex or superior colliculus. It affects the efferent pathway of the pupillary reflex.
Recovery has progressed smoothly and the nurse is planning with Mr. Hall for discharge. Which of the following activities is most appropriate for Mr. Hall to do?
- A. Maintain bed rest and isometric exercises for the first week following discharge
- B. When sitting, use a deep, soft, easy chair for the first month to cushion the joint while healing continues
- C. Following 2 weeks of exercise at home, he may begin driving the car again
- D. Intermittently sit for short periods followed by short, frequent walks
Correct Answer: D
Rationale: Short walks promote circulation and healing.
When assessing a patient diagnosed with multiple sclerosis (MS), which of the following would require immediate action by the healthcare provider?
- A. Fatigue and depression
- B. Paresthesia and tremor
- C. Nystagmus and diplopia
- D. Dysphagia and congested cough
Correct Answer: D
Rationale: Dysphagia and a congested cough indicate potential aspiration risk, which requires immediate intervention to prevent respiratory complications.
A medical-surgical nurse works with a patient diagnosed with a somatic system disorder. Care planning is facilitated by understanding that the patient will probably:
- A. readily seek psychiatric counseling.
- B. be resistant to accepting psychiatric help.
- C. attend psychotherapy sessions without encouragement.
- D. be eager to discover the true reasons for physical symptoms.
Correct Answer: B
Rationale: The correct answer is B because individuals with somatic symptom disorders often resist psychiatric help due to their strong belief that their physical symptoms have a medical, not psychological, cause. This resistance can stem from fear of being labeled as "crazy" or of not being taken seriously. Therefore, the nurse should be aware of this resistance and approach the patient with empathy and understanding.
A: This is incorrect because individuals with somatic symptom disorders often do not readily seek psychiatric counseling due to their belief that their symptoms are purely physical.
C: This is incorrect because individuals with somatic symptom disorders may not attend psychotherapy sessions without encouragement due to their resistance to psychiatric help.
D: This is incorrect because individuals with somatic symptom disorders may not be eager to discover the true reasons for physical symptoms as they strongly believe in the medical cause.