Nokea
A patient who was in an automobile accident 30 minutes ago reports that he or she is unable to move his or her legs. What is the best response?
- A. Swelling due to the initial trauma may make the injury seem more severe than it actually is. A more accurate assessment will be made once the swelling goes down.
- B. Swelling owing to the initial trauma prevents you from moving your legs.
- C. There are good rehabilitation centers that will help restore sensation to your legs.
- D. You should have been wearing your seatbelt.
Correct Answer: A
Rationale: Swelling after trauma can temporarily affect mobility and should be addressed before making long-term predictions.
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What gland produces a secretion that causes fight-or-flight responses in effectors?
- A. adrenal medulla
- B. salivatory gland
- C. reproductive gland
- D. thymus
Correct Answer: A
Rationale: The correct answer is A: adrenal medulla. The adrenal medulla is part of the adrenal gland and secretes adrenaline and noradrenaline in response to stress, leading to fight-or-flight responses. The salivary gland produces saliva, the reproductive gland produces sex hormones, and the thymus produces T-cells for the immune system, none of which are related to fight-or-flight responses.
While collecting data the nurse learns that a patient with a neurological illness has not had a sense of smell for several decades. Which part of the central nervous system should the nurse question as being damaged in this patient?
- A. Brainstem
- B. Occipital lobe
- C. Hypothalamus
- D. Temporal lobe
Correct Answer: D
Rationale: The olfactory nerve (cranial nerve I) originates in the temporal lobe, and damage to this area can result in anosmia (loss of smell). The brainstem, occipital lobe, and hypothalamus are not directly involved in the sense of smell. Assessing olfactory function can provide clues about neurological damage.
To determine the extent of Mr. Smith's head injury, what baseline nursing assessment is most important?
- A. Respiratory status
- B. Motor strength
- C. Urinary output
- D. Gastrointestinal function
Correct Answer: A
Rationale: Respiratory status is crucial in assessing head injuries due to potential brainstem involvement.
What is the most common diagnostic test used to assess musculoskeletal disorders?
- A. Myelogram
- B. Arthroscopy
- C. Standard x-ray
- D. Magnetic resonance imaging (MRI)
Correct Answer: C
Rationale: Standard x-rays are widely used for initial assessments.
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.