Nokea
A patient with a spinal cord injury has spinal shock. The nurse plans care for the patient based on what knowledge?
- A. Rehabilitation measures cannot be initiated until spinal shock has resolved.
- B. The patient will need continuous monitoring for hypotension, tachycardia, and hypoxemia.
- C. Resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder.
- D. The patient will have complete loss of motor and sensory functions below the level of the injury but autonomic functions are not affected.
Correct Answer: C
Rationale: Spinal shock resolves with the return of reflex activity.
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Cell bodies for the motor supply of the trigeminal nerve lie
- A. Hypothalamus
- B. Midbrain
- C. Posterior to cerebral aqueduct
- D. Cerebral cortex
Correct Answer: B
Rationale: The motor nucleus of the trigeminal nerve is located in the midbrain. It supplies muscles of mastication, such as the masseter and temporalis.
What is the major focus for care today for a patient who is 1 day post-operative after a left below-the-knee amputation?
- A. To attain pain control for phantom pain.
- B. To monitor for signs of sufficient tissue perfusion.
- C. To assist the patient to ambulate as soon as possible.
- D. To elevate the residual limb when the patient is supine.
Correct Answer: B
Rationale: Ensuring adequate tissue perfusion is critical in the immediate post-operative period to prevent complications.
The nurse is caring for a patient diagnosed with a cerebral tumor. For which function should the nurse expect to assess an abnormality?
- A. Reflex movement
- B. Movement and speech
- C. Coordination and posture
- D. Heart rate and respiratory rate
Correct Answer: B
Rationale: A cerebral tumor in the frontal lobe may affect movement and speech, as this area contains the motor cortex and Broca's area. Reflex movements are controlled by the spinal cord, coordination by the cerebellum, and heart rate by the medulla. Assessing movement and speech is critical for localizing the tumor's effects.
A person who experiences an aura as part of his/her seizure pattern should be instructed to
- A. lie down in a safe place
- B. take additional anticonvulsant medication
- C. call an ambulance
- D. exercise vigorously
Correct Answer: A
Rationale: Lying down in a safe place can prevent injury during a seizure.
You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to the LPN/LVN?
- A. Complete admission assessment.
- B. Set up oxygen and suction equipment.
- C. Place a padded tongue blade at bedside.
- D. Pad the side rails before patient arrives.
Correct Answer: D
Rationale: Padding the side rails is a safety measure that can be done by an LPN/LVN without requiring complex assessment skills.