Nokea
A patient recovering from an acute exacerbation of RA tells the nurse that she is too tired to bathe. What should the nurse do for this patient?
- A. Give the patient a bed bath to conserve her energy.
- B. Allow the patient a rest period before showering with the nurse's help.
- C. Tell the patient that she can skip bathing if she will walk in the hall later.
- D. Inform the patient that it is important for her to maintain self-care activities.
Correct Answer: A
Rationale: Conserving energy is critical during flares.
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When assessing a patient for signs of increased intracranial pressure (ICP), the nurse should look for:
- A. Changes in level of consciousness, headache, and vomiting.
- B. Normal pupil size and reaction.
- C. Absence of nausea or vomiting.
- D. Clear and coordinated movements.
Correct Answer: A
Rationale: Increased intracranial pressure (ICP) is associated with changes in consciousness, headache, and vomiting. Normal pupil size, absence of nausea, and clear movements are not indicative of ICP.
A nurse counseling a patient diagnosed with dissociative identity disorder (DID) should understand that the assessment of highest priority is:
- A. risk for self-harm
- B. cognitive functioning
- C. identification of drug abuse
- D. readiness to reestablish identity or memory
Correct Answer: A
Rationale: The correct answer is A: risk for self-harm. In patients with DID, the primary concern is ensuring their safety due to the high risk of self-harm or suicide. Assessing this risk is crucial for immediate intervention to prevent harm. Choice B, cognitive functioning, may be important but is secondary to ensuring patient safety. Choice C, identification of drug abuse, is relevant but not as urgent as addressing the risk for self-harm. Choice D, readiness to reestablish identity or memory, is important but not as critical as ensuring the patient's safety. Therefore, assessing the risk for self-harm takes precedence in the care of a patient with DID.
What is the role of semaphorins and Eph ligands in development of the nervous system?
- A. The semaphorins and Eph ligands are growth factors that stimulate cell division of neurons.
- B. The semaphorins and Eph ligands act as signals for the outgrowth of neuronal growth cones; in general, both lead growth cones to turn away.
- C. The semaphorins and Eph ligands act as signals for the outgrowth of neuronal growth cones; in general, both lead growth cones to come toward them.
- D. The semaphorins and Eph ligands are cell-cell adhesion molecules that bind adjacent neurons together.
Correct Answer: B
Rationale: Semaphorins and Eph ligands act as guidance cues for growing axons. They generally function as repulsive signals, causing growth cones to turn away from inappropriate regions. This ensures precise navigation of axons to their correct targets, which is essential for establishing functional neural circuits.
To assess cranial nerve VIII (Vestibulocochlear nerve), the nurse should:
- A. Perform a hearing test and assess balance.
- B. Evaluate the patient's ability to swallow.
- C. Inspect the patient's throat.
- D. Palpate the patient's neck.
Correct Answer: A
Rationale: Cranial nerve VIII (Vestibulocochlear nerve) is responsible for hearing and balance. A hearing test and balance assessment evaluate its function. Swallowing, throat inspection, and neck palpation are unrelated.
The polyneuropathic pattern of sensory loss suggests presence of the following syndrome:
- A. numbness & pain in distal parts of extremities
- B. numbness & analgesia in half of the body
- C. pain & sensory ataxia in half of the body
- D. analgesia & sensory ataxia in proximal parts of extremities
Correct Answer: A
Rationale: Numbness and pain in distal parts of extremities is the correct answer because polyneuropathy typically affects the longest nerves first, leading to a glove-and-stocking pattern of sensory loss. This condition is often caused by systemic diseases such as diabetes, vitamin deficiencies, or toxic exposures.