Nokea
All of these nursing activities are included in the care plan for a 78-year-old man with Parkinson's disease who has been referred to your home health agency. Which ones will you delegate to a nursing assistant (NA)? (Choose all that apply.)
- A. Check for orthostatic changes in pulse and blood pressure.
- B. Monitor for improvement in tremor after levodopa (L-dopa) is given.
- C. Remind the patient to allow adequate time for meals.
- D. Monitor for abnormal involuntary jerky movements of extremities.
Correct Answer: C
Rationale: Tasks like reminding the patient about meals and assisting with exercises are suitable for delegation to a nursing assistant.
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In performing range of motion (ROM) with a patient, the nurse puts each joint through its full movement. Which joints are capable of abduction and adduction (select all that apply)?
- A. Hip
- B. Knee
- C. Wrist
- D. Elbow
Correct Answer: A
Rationale: Hips, thumbs, and shoulders allow abduction/adduction.
Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation?
- A. Hemorrhagic skin rash
- B. Edema
- C. Cyanosis
- D. Dyspnea on exertion
Correct Answer: A
Rationale: A hemorrhagic skin rash is a hallmark sign of disseminated intravascular coagulation (DIC), a severe complication of meningitis. DIC occurs due to widespread activation of the clotting cascade, leading to microthrombi and subsequent bleeding. This condition requires urgent medical intervention to prevent organ failure and death.
Which assessment finding suggests an issue with cranial nerve XI (Accessory nerve)?
- A. Weakness or atrophy of the sternocleidomastoid and trapezius muscles.
- B. Normal shoulder shrug and head turn strength.
- C. Equal and symmetrical shoulder movement.
- D. Clear and normal speech.
Correct Answer: A
Rationale: Cranial nerve XI (Accessory nerve) controls the sternocleidomastoid and trapezius muscles. Weakness or atrophy in these muscles indicates dysfunction. Normal strength, symmetrical movement, and clear speech are normal findings.
Which layer of the uterus is shed during menstruation?
- A. Perimetrium
- B. Myometrium
- C. Endometrium
- D. Ectometrium
Correct Answer: C
Rationale: The endometrium is the correct answer because it is the inner lining of the uterus that thickens in preparation for pregnancy and is shed during menstruation if fertilization does not occur. This cyclical process is regulated by hormones such as estrogen and progesterone and is essential for reproductive health.
The patient with a cervical SCI has been placed in fixed skeletal traction with a halo fixation device. When caring for this patient the nurse may delegate which action(s) to the LPN/LVN? (Chooseone that doesn't apply.)
- A. Check the patient's skin for pressure from device.
- B. Assess the patient's neurologic status for changes.
- C. Observe the halo insertion sites for signs of infection.
- D. Clean the halo insertion sites with hydrogen peroxide.
Correct Answer: B
Rationale: Skin checks, observing for infection, and cleaning insertion sites are tasks that can be performed by an LPN/LVN under supervision.