Nokea
A patient with diabetes presents to the clinic and is diagnosed with a mononeuropathy. This patient's nursing care should involve which of the following?
- A. Protection of the affected limb from injury
- B. Passive and active ROM exercises for the affected limb
- C. Education about improvements to glycemic control
- D. Interventions to prevent contractures
Correct Answer: A
Rationale: Mononeuropathy causes sensory loss, requiring protection of the affected limb from injury. ROM exercises, glycemic control education, and contracture prevention are not primary interventions.
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A patient with MS has been admitted to the hospital following an acute exacerbation. When planning the patient's care, the nurse addresses the need to enhance the patient's bladder control. What aspect of nursing care is most likely to meet this goal?
- A. Establish a timed voiding schedule.
- B. Avoid foods that change the pH of urine.
- C. Perform intermittent catheterization q6h.
- D. Administer anticholinergic drugs as ordered.
Correct Answer: A
Rationale: A timed voiding schedule promotes bladder control in MS by training the bladder. Catheterization and anticholinergics are not first-line, and urine pH is irrelevant.
A patient with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a patient with this diagnosis?
- A. Pain upon ankle dorsiflexion of the foot
- B. Neck flexion produces flexion of knees and hips
- C. Inability to stand with eyes closed and arms extended without swaying
- D. Numbness and tingling in the lower extremities
Correct Answer: B
Rationale: A positive Brudzinski's sign, where neck flexion causes knee and hip flexion, is a hallmark of bacterial meningitis due to meningeal irritation. Pain on dorsiflexion (Homans' sign) relates to thrombosis, Romberg's sign to balance issues, and numbness to peripheral neuropathy, none of which are typical for meningitis.
A patient with Guillain-Barr?© syndrome has experienced a sharp decline in vital capacity. What is the nurse's most appropriate action?
- A. Administer bronchodilators as ordered.
- B. Remind the patient of the importance of deep breathing and coughing exercises.
- C. Prepare to assist with intubation.
- D. Administer supplementary oxygen by nasal cannula.
Correct Answer: C
Rationale: A sharp decline in vital capacity in Guillain-Barr?© syndrome indicates respiratory muscle weakness, necessitating preparation for intubation to ensure adequate oxygenation. Bronchodilators and oxygen are insufficient, and breathing exercises may be impossible.
A patient with suspected Creutzfeldt-Jakob disease (CJD) is being admitted to the unit. The nurse would expect what diagnostic test to be ordered for this patient?
- A. Cerebral angiography
- B. ABG analysis
- C. CT
- D. EEG
Correct Answer: D
Rationale: EEG shows a characteristic pattern in CJD, aiding diagnosis. CT may rule out other conditions, but angiography and ABGs are not diagnostic for CJD.
The critical care nurse is admitting a patient in myasthenic crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this patient?
- A. Suctioning secretions
- B. Facilitating ABG analysis
- C. Providing ventilatory assistance
- D. Administering tube feedings
Correct Answer: C
Rationale: Myasthenic crisis causes severe muscle weakness, risking respiratory failure, so ventilatory assistance is the priority. Suctioning, ABGs, and feeding are secondary.