Nokea
A patient with lower back pain is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should prioritize what action?
- A. Positioning the patient with the head of the bed elevated 45 degrees
- B. Administering IV morphine sulfate to prevent headache
- C. Limiting fluids for the next 12 hours
- D. Helping the patient perform deep breathing and coughing exercises
Correct Answer: A
Rationale: Elevating the head 30-45 degrees post-myelography prevents contrast dye irritation in the brain, reducing headache risk. Fluids are encouraged, morphine is not standard, and breathing exercises are unnecessary.
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A patient in the OR goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows that the area of the brain that regulates body temperature is which of the following?
- A. Cerebellum
- B. Thalamus
- C. Hypothalamus
- D. Midbrain
Correct Answer: C
Rationale: The hypothalamus regulates body temperature via vasoconstriction or vasodilatation. The cerebellum, thalamus, and midbrain do not directly control temperature.
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 72-year-old man has been brought to his primary care provider by his daughter, who claims that he has been experiencing uncharacteristic lapses in memory. What principle should underlie the nurses assessment and management of this patient?
- A. Loss of short-term memory is normal in older adults, but loss of long-term memory is pathologic.
- B. Lapses in memory in older adults are considered benign unless they have negative consequences.
- C. Gradual increases in confusion accompany the aging process.
- D. Thorough assessment is necessary because changes in cognition are always considered to be pathologic.
Correct Answer: D
Rationale: Cognitive changes in older adults are not assumed normal and require thorough assessment to rule out pathology like dementia. Memory and judgment typically remain intact with aging.
In the course of a focused neurologic assessment, the nurse is palpating the patients major muscle groups at rest and during passive movement. Data gleaned from this assessment will allow the nurse to describe which of the following aspects of neurologic function?
- A. Muscle dexterity
- B. Muscle tone
- C. Dysfunction of basal ganglia
- D. Motor symmetry
Correct Answer: B
Rationale: Muscle tone is evaluated by palpating muscles at rest and during passive movement. Dexterity, basal ganglia function, and symmetry require different assessments like coordination or side-to-side comparison.
The nurse is performing a neurologic assessment of a patient whose injuries have rendered her unable to follow verbal commands. How should the nurse proceed with assessing the patients level of consciousness (LOC)?
- A. Assess the patients vital signs and correlate these with the patients baselines.
- B. Assess the patients eye opening and response to stimuli.
- C. Document that the patient currently lacks a level of consciousness.
- D. Facilitate diagnostic testing in an effort to obtain objective data.
Correct Answer: B
Rationale: LOC in non-responsive patients is assessed by eye opening and responses to stimuli, per the Glasgow Coma Scale. Vital signs and testing are supplementary, and lack of response doesn't mean no consciousness.