Nokea
After talking with the health care provider, the patient asks what the blood-brain barrier does. What is the best description that the nurse can give the patient?
- A. Protects the brain from external trauma
- B. Protects against harmful blood-borne agents
- C. Provides for flexibility while protecting the spinal cord
- D. Forms the outer layer of protective membranes around the brain and spinal cord
Correct Answer: B
Rationale: The blood-brain barrier protects the brain against harmful substances in the blood.
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Which patient should be assigned to the traveling nurse, new to neurologic nursing care, who has been on the neurologic unit for 1 week?
- A. A 34-year-old patient newly diagnosed with multiple sclerosis (MS)
- B. A 68-year-old patient with chronic amyotrophic lateral sclerosis (ALS)
- C. A 56-year-old patient with Guillain-Barré syndrome (GBS) in respiratory distress
- D. A 25-year-old patient admitted with C4 level spinal cord injury (SCI)
Correct Answer: A
Rationale: A newly diagnosed MS patient would likely have stable conditions and be appropriate for a less experienced nurse.
A young male client visits a nurse with a complaint of chronic tension headaches. Which of the following is the most appropriate nursing instruction to manage the client?
- A. Instructing the client to monitor for signs of bruising or bleeding
- B. Suggesting eating and swallowing techniques that reduce the potential for aspiration
- C. Counseling on alternate therapies
- D. Advising the client to change sleeping positions frequently
Correct Answer: C
Rationale: Alternate therapies, such as relaxation techniques, can help manage tension headaches.
When is a fat embolism most likely to occur?
- A. 24 to 48 hours following a fractured tibia
- B. 36 to 72 hours following a skull fracture
- C. 4 to 5 days following a fractured femur
- D. 5 to 6 days following a pelvic fracture
Correct Answer: A
Rationale: Fat embolism is most common after tibial fractures within 24-48 hours.
The action potential of a neuron
- A. is initiated by efflux of Na+
- B. is terminated by efflux of K+
- C. declines in amplitude as it moves along the axon
- D. results in a transient reversal of the concentration gradient of Na+ across the cell membrane
Correct Answer: B
Rationale: The action potential is initiated by the influx of Na+ through voltage-gated sodium channels, causing depolarization. It is terminated by the efflux of K+ through voltage-gated potassium channels, leading to repolarization. The action potential does not decline in amplitude as it propagates along the axon (all-or-none principle), and there is a net movement of Na+ and K+ across the membrane during the process.
During muscle strength testing, the patient has active movement against gravity and some resistance to pressure. What score should the nurse give this finding?
- A. 2
- B. 3
- C. 4
- D. 5
Correct Answer: C
Rationale: Grade 4 indicates movement against gravity and moderate resistance.