Nokea
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.
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A 73-year-old man comes to the clinic complaining of weakness and loss of sensation in his feet and legs. Assessment of the patient shows decreased reflexes bilaterally. Why would it be a challenge to diagnose a peripheral neuropathy in this patient?
- A. Older adults are often vague historians.
- B. The elderly have fewer peripheral nerves than younger adults.
- C. Many older adults are hesitant to admit that their body is changing.
- D. Many symptoms can be the result of normal aging process.
Correct Answer: D
Rationale: Symptoms like decreased reflexes in peripheral neuropathy can mimic normal aging, complicating diagnosis. Older adults do not necessarily have fewer nerves or withhold information.
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.
A patient is admitted through the ED with suspected St. Louis encephalitis. The unique clinical feature of St. Louis encephalitis will make what nursing action a priority?
- A. Serial assessments of hemoglobin levels
- B. Blood glucose monitoring
- C. Close monitoring of fluid balance
- D. Assessment of pain along dermatomes
Correct Answer: C
Rationale: St. Louis encephalitis is associated with SIADH, causing hyponatremia, so monitoring fluid balance is critical. Hemoglobin, glucose, and dermatomal pain are not specific to this condition.
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.
A 35-year-old woman is diagnosed with a peripheral neuropathy. When making her plan of care, the nurse knows to include what in patient teaching? Select all that apply.
- A. Inspect the lower extremities for skin breakdown.
- B. Footwear needs to be accurately sized.
- C. Immediate family members should be screened for the disease.
- D. Assistive devices may be needed to reduce the risk of falls.
- E. Dietary modifications are likely necessary.
Correct Answer: A,B,D
Rationale: Peripheral neuropathy requires inspecting for skin breakdown, proper footwear, and assistive devices to prevent falls. It is not genetic, and diet is unrelated.