Nokea
A patient with paraplegia has developed an irritable bladder with reflex emptying. What will be most helpful for the nurse to teach the patient?
- A. Hygiene care for an indwelling urinary catheter
- B. How to perform intermittent self-catheterization
- C. To empty the bladder with manual pelvic pressure in coordination with reflex voiding patterns
- D. That a urinary diversion, such as an ileal conduit, is the easiest way to handle urinary elimination
Correct Answer: C
Rationale: Manual techniques align with reflex voiding patterns.
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To prevent strain on Mr. Tucker's back muscles, which nursing action is INAPPROPRIATE?
- A. To place him on bed pan, logroll using a turning sheet
- B. When lying on his side, flex upper leg and place a pillow between his knees
- C. When lying on his back, place pillows under entire length of his knees
- D. To turn him on his side, gently turn his shoulders and upper trunk first, prop with a pillow, then turn his pelvis and lower limbs
Correct Answer: D
Rationale: Turning the pelvis and lower limbs last can strain back muscles.
During neurologic assessment of the older adult, what should the nurse expect to find?
- A. Absent deep tendon reflexes
- B. Below-average intelligence score
- C. Decreased sensation of touch and temperature
- D. Decreased frequency of spontaneous awakening
Correct Answer: C
Rationale: Older adults often exhibit decreased sensation of touch and temperature.
A glove-&-stocking pattern of sensory disturbance usually develops with disease in:
- A. peripheral nerves
- B. the spinal cord
- C. the brainstem
- D. the thalamus
Correct Answer: A
Rationale: Peripheral nerves are the correct answer because a glove-and-stocking pattern of sensory loss is characteristic of peripheral neuropathy. This pattern occurs due to the length-dependent nature of peripheral nerve damage, where the longest nerves (those supplying the hands and feet) are affected first, leading to distal sensory deficits.
Which of the following are the parts of neurons?
- A. brain, spinal cord, and vertebral column
- B. dendrite, axon, and cell body
- C. sensory and motor
- D. cortex, medulla and sheath
Correct Answer: B
Rationale: Neurons are the basic building blocks of the nervous system and consist of three main parts: dendrites, axons, and the cell body. Dendrites receive signals from other neurons, the cell body contains the nucleus and organelles, and the axon transmits signals to other neurons or target cells. These components work together to facilitate communication within the nervous system, enabling sensory perception, motor control, and cognitive functions.
In discharge planning with Mrs. Post, it will be important to teach her to avoid exposure to the sun because
- A. concurrent use of steroids and sun exposure lessens the drug's effectiveness
- B. sunlight may cause ulceration of skin lesions
- C. sunlight may aggravate rash and arthritis
- D. the skin will be more sensitive to burning
Correct Answer: C
Rationale: Sunlight exposure can worsen lupus symptoms.