Nokea
An elderly patient is being discharged home. The patient lives alone and has atrophy of his olfactory organs. The nurse tells the patients family that it is essential that the patient have what installed in the home?
- A. Grab bars
- B. Nonslip mats
- C. Baseboard heaters
- D. A smoke detector
Correct Answer: D
Rationale: Olfactory atrophy impairs smell, increasing the risk of missing smoke or gas. A smoke detector is critical for safety. Grab bars and mats address mobility, and heaters are unrelated to olfactory deficits.
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A nurse is assessing reflexes in a patient with hyperactive reflexes. When the patients foot is abruptly dorsiflexed, it continues to beat two to three times before settling into a resting position. How would the nurse document this finding?
- A. Rigidity
- B. Flaccidity
- C. Clonus
- D. Ataxia
Correct Answer: C
Rationale: Clonus is characterized by rhythmic muscle contractions, such as foot beating after dorsiflexion, indicating hyperactive reflexes. Rigidity is increased muscle tone, flaccidity is lack of tone, and ataxia is uncoordinated movement.
A patient with lower back pain is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should prioritize what action?
- A. Positioning the patient with the head of the bed elevated 45 degrees
- B. Administering IV morphine sulfate to prevent headache
- C. Limiting fluids for the next 12 hours
- D. Helping the patient perform deep breathing and coughing exercises
Correct Answer: A
Rationale: Elevating the head 30-45 degrees post-myelography prevents contrast dye irritation in the brain, reducing headache risk. Fluids are encouraged, morphine is not standard, and breathing exercises are unnecessary.
A patient in the OR goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows that the area of the brain that regulates body temperature is which of the following?
- A. Cerebellum
- B. Thalamus
- C. Hypothalamus
- D. Midbrain
Correct Answer: C
Rationale: The hypothalamus regulates body temperature via vasoconstriction or vasodilatation. The cerebellum, thalamus, and midbrain do not directly control temperature.
What term is used to describe the fibrous connective tissue that hugs the brain closely and extends into every fold of the brains surface?
- A. Dura mater
- B. Arachnoid
- C. Fascia
- D. Pia mater
Correct Answer: D
Rationale: The pia mater is the innermost meningeal layer, closely adhering to the brain's surface and following its contours. Dura mater is the outermost layer, arachnoid is the middle layer, and fascia is not a meningeal structure.
A patient is admitted to the medical unit with an exacerbation of multiple sclerosis. When assessing this patient, the nurse has the patient stick out her tongue and move it back and forth. What is the nurse assessing?
- A. Function of the hypoglossal nerve
- B. Function of the vagus nerve
- C. Function of the spinal nerve
- D. Function of the trochlear nerve
Correct Answer: A
Rationale: Tongue movement is controlled by the hypoglossal nerve (XII). The vagus nerve affects throat and voice, spinal nerves control body muscles, and the trochlear nerve moves the eye.