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A patient with a head injury opens the eyes to painful stimulation, mumbles incoherently when stimulated, and does not respond to a verbal command to move but localizes to painful stimulus. The nurse records the patient's Glasgow Coma Scale score as:
- A. 9
- B. 11
- C. 13
- D. 15
Correct Answer: B
Rationale: The correct answer is B: 11. According to the Glasgow Coma Scale (GCS), this patient scores 4 for eye opening (to painful stimulus), 3 for verbal response (mumbles incoherently), and 4 for motor response (localizes to painful stimulus), totaling 11. This indicates moderate brain injury. Choice A (9) is incorrect because the patient localizes to pain, indicating a higher level of responsiveness than a GCS score of 9. Choice C (13) and D (15) are also incorrect as the patient's responses do not align with a higher GCS score due to the patient's inability to follow verbal commands effectively.
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The nurse is performing a neurological assessment and notes a positive Romberg test. What does this finding indicate?
- A. Cranial nerve dysfunction.
- B. Cerebellar ataxia or vestibular dysfunction.
- C. Peripheral neuropathy.
- D. Increased intracranial pressure.
Correct Answer: B
Rationale: The Romberg test assesses balance and postural stability. A positive Romberg test indicates a deficit in proprioception, which is commonly seen in cerebellar ataxia or vestibular dysfunction. The cerebellum and vestibular system play crucial roles in maintaining balance and coordination. Cranial nerve dysfunction (A) does not directly affect balance. Peripheral neuropathy (C) primarily affects sensation and motor function, not balance. Increased intracranial pressure (D) may present with other neurological signs, but not specifically a positive Romberg test. Therefore, the correct answer is B.
A young man is concerned about a hard mass he has just noticed in the midline of his palate. On examination, it is indeed hard and in the midline. There are no mucosal abnormalities associated with this lesion. He is experiencing no other symptoms. What will you tell him is the most likely diagnosis?
- A. Leukoplakia
- B. Torus palatinus
- C. Thrush (candidiasis)
- D. Kaposi's sarcoma
Correct Answer: B
Rationale: The most likely diagnosis for a hard mass in the midline of the palate with no associated mucosal abnormalities is Torus palatinus (Choice B). This is a benign bony growth that typically occurs in the midline of the hard palate. The absence of mucosal abnormalities and the hard nature of the mass are indicative of a bony growth rather than a soft tissue lesion like leukoplakia (Choice A), thrush (Choice C), or Kaposi's sarcoma (Choice D). Leukoplakia is a white patch that cannot be scraped off, thrush is a fungal infection causing creamy white lesions, and Kaposi's sarcoma usually presents as purplish lesions in immunocompromised individuals. In this case, the hard midline mass without mucosal changes points towards Torus palatinus as the most likely diagnosis.
During a neurological assessment, the nurse tests cranial nerve VII. What is the primary function of this nerve?
- A. Hearing and balance.
- B. Facial movements and expression.
- C. Swallowing and speech.
- D. Eye movement.
Correct Answer: B
Rationale: The correct answer is B: Facial movements and expression. Cranial nerve VII, also known as the facial nerve, primarily controls facial muscles responsible for facial expressions, such as smiling and frowning. It also innervates the muscles involved in closing the eyes and controlling the forehead and mouth movements. Other choices are incorrect because cranial nerve VII is not primarily responsible for hearing and balance (A), swallowing and speech (C), or eye movement (D). The key function of cranial nerve VII lies in its role in facial movements and expressions.
Which of the following findings is most concerning during a peripheral vascular assessment?
- A. Capillary refill time of 2 seconds.
- B. Equal pulses bilaterally.
- C. Unilateral edema.
- D. Warm skin temperature in both extremities.
Correct Answer: C
Rationale: The correct answer is C, unilateral edema. This finding is most concerning as it may indicate a blockage or dysfunction in the lymphatic or venous system, potentially leading to serious conditions like deep vein thrombosis. In contrast, A and D are normal findings indicating good peripheral circulation, while B is also normal and indicates balanced blood flow.
Which of the following are open-ended questions? Select all that apply.
- A. Tell me about your headaches.
- B. Describe your chest pain.
- C. Point to where the pain is.
- D. What do you expect from me as your nurse?
Correct Answer: C
Rationale: The correct answer is C because open-ended questions encourage patients to provide detailed responses without limiting them to specific options. Choice A and B are closed-ended questions as they prompt specific information. Choice D is a leading question that suggests a specific response, making it closed-ended.