Nokea
A patient scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the patient for the MRI should prioritize which of the following actions?
- A. Withholding stimulants 24 to 48 hours prior to exam
- B. Removing all metal-containing objects
- C. Instructing the patient to void prior to the MRI
- D. Initiating an IV line for administration of contrast
Correct Answer: B
Rationale: MRI uses strong magnetic fields, making removal of metal objects critical to prevent injury or image distortion. Withholding stimulants applies to EEG, voiding to lumbar puncture, and IV contrast to CT scans.
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The patient in the ED has just had a diagnostic lumbar puncture. To reduce the incidence of a postlumbar puncture headache, what is the nurses most appropriate action?
- A. Position the patient prone.
- B. Position the patient supine with the head of bed flat.
- C. Position the patient left side-lying.
- D. Administer acetaminophen as ordered.
Correct Answer: A
Rationale: Prone positioning after lumbar puncture minimizes cerebrospinal fluid leakage, reducing headache risk. Supine or side-lying positions are less effective, and acetaminophen is not a preventive measure.
A patient is being given a medication that stimulates her parasympathetic system. Following administration of this medication, the nurse should anticipate what effect?
- A. Constricted pupils
- B. Dilated bronchioles
- C. Decreased peristaltic movement
- D. Relaxed muscular walls of the urinary bladder
Correct Answer: A
Rationale: Parasympathetic stimulation causes pupil constriction, bronchoconstriction, increased peristalsis, and bladder contraction. The other options reflect sympathetic effects.
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.
The physician has ordered a somatosensory evoked responses (SERs) test for a patient for whom the nurse is caring. The nurse is justified in suspecting that this patient may have a history of what type of neurologic disorder?
- A. Hypothalamic disorder
- B. Demyelinating disease
- C. Brainstem deficit
- D. Diabetic neuropathy
Correct Answer: B
Rationale: SERs detect slowed nerve conduction, common in demyelinating diseases like multiple sclerosis. They are not used for hypothalamic, brainstem, or diabetic neuropathy diagnoses.
A nurse is assessing reflexes in a patient with hyperactive reflexes. When the patients foot is abruptly dorsiflexed, it continues to beat two to three times before settling into a resting position. How would the nurse document this finding?
- A. Rigidity
- B. Flaccidity
- C. Clonus
- D. Ataxia
Correct Answer: C
Rationale: Clonus is characterized by rhythmic muscle contractions, such as foot beating after dorsiflexion, indicating hyperactive reflexes. Rigidity is increased muscle tone, flaccidity is lack of tone, and ataxia is uncoordinated movement.