Nokea
An adult patient who experiences the loss of his/her gag reflex following a closed-head and suspected spinal injury may have suffered an injury to which of the following cranial nerves?
- A. Cranial nerve X (vagus)
- B. Cranial nerve III (oculomotor)
- C. Cranial nerve XII (hypoglossal)
- D. Cranial nerve IX (glossopharyngeal)
Correct Answer: A
Rationale: The correct answer is A: Cranial nerve X (vagus). The vagus nerve is responsible for the gag reflex. A loss of gag reflex in a patient with a closed-head and spinal injury indicates damage to the vagus nerve. The other choices are incorrect because: B (oculomotor) is responsible for eye movement, C (hypoglossal) is responsible for tongue movement, and D (glossopharyngeal) is responsible for swallowing and taste sensation. None of these cranial nerves are directly related to the gag reflex.
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A resident who is at risk for pressure injuries may have
- A. An alternating pressure mattress
- B. A bariatric bed
- C. An electric bed
- D. A closed bed
Correct Answer: A
Rationale: The correct answer is A: An alternating pressure mattress. This type of mattress helps reduce pressure on specific areas of the body by alternating pressure points, which can prevent pressure injuries. The other choices, B: A bariatric bed, C: An electric bed, and D: A closed bed, do not directly address the prevention of pressure injuries. Bariatric beds are designed for heavier individuals, electric beds assist with adjusting positions, and closed beds do not offer the necessary pressure relief for someone at risk of pressure injuries. Therefore, A is the most appropriate choice for addressing the specific needs of a resident at risk for pressure injuries.
When applying the Rule of Nines to infants:
- A. It is not reliable
- B. The body is proportionally larger in infants than in adults
- C. The head is proportionally larger in infants than in adults
- D. The legs are proportionally larger in infants than in adults
Correct Answer: C
Rationale: The Rule of Nines is used to estimate the percentage of body surface area burned. In infants, the head is proportionally larger compared to adults, making it a key area to assess accurately. This is crucial for determining the extent of burns and guiding treatment. Choice C is correct because it highlights the specific anatomical difference in infants. Choices A, B, and D are incorrect as they do not address the unique proportionality of the infant head compared to adults, which is essential in burn assessment for this age group.
Repositioning a resident on a mechanical ventilator must be done at least every
- A. 5 hours
- B. 4 hours
- C. 3 hours
- D. 2 hours
Correct Answer: B
Rationale: The correct answer is B (4 hours) because repositioning a resident on a mechanical ventilator is crucial to prevent pressure ulcers and maintain proper ventilation. Repositioning every 4 hours helps distribute pressure, improve circulation, and prevent skin breakdown. Choice A (5 hours) is too long, increasing the risk of complications. Choice C (3 hours) may be too frequent and could disrupt the patient's rest. Choice D (2 hours) is too frequent and may not allow enough time for the patient to rest and heal. Therefore, B is the most appropriate interval for repositioning a resident on a mechanical ventilator.
A clean-catch specimen is also called a __________ specimen because the first and last voiding are not included in the urine sample.
- A. Contaminated
- B. Cleansing
- C. Stop and start
- D. Midstream
Correct Answer: D
Rationale: The correct answer is D: Midstream. A clean-catch specimen, also known as midstream urine, is collected during the middle of urination to avoid contamination from the initial and final urine flow. This method minimizes external bacteria and cells from the urethra. Choice A, contaminated, is incorrect as the goal of a clean-catch specimen is to reduce contamination. Choice B, cleansing, is unrelated to the specific urine collection process. Choice C, stop and start, does not accurately describe the method used for collecting a clean-catch specimen.
A general rule for bathing a person is
- A. Wash from dirtiest to cleanest
- B. Wash from cleanest to dirtiest
- C. Wash body parts in whatever order the resident prefers
- D. Wash body parts in whatever order the nursing assistant prefers
Correct Answer: B
Rationale: The correct answer is B: Wash from cleanest to dirtiest. This approach helps prevent spreading dirt and bacteria from dirty areas to cleaner ones, reducing the risk of infections. It also maintains hygiene standards and promotes overall cleanliness. Choice A is incorrect as it can lead to cross-contamination. Choice C is not ideal as it may not prioritize effective cleaning. Choice D is incorrect as it disregards the resident's preferences and can be unhygienic.