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Benzodiazepine medication is being used to help manage this patient's behavior?
- A. Sertraline (Zoloft)
- B. Donepezil (Aricept)
- C. Lorazepam (Ativan)
- D. Risperidone (Risperdal)
Correct Answer: C
Rationale: Lorazepam is a benzodiazepine used for agitation
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When assessing cranial nerve V (Trigeminal nerve), the nurse should:
- A. Test the sensation of the face and palpate the masseter muscles.
- B. Check the patient's ability to hear.
- C. Examine the patient's sense of smell.
- D. Assess the patient's swallowing ability.
Correct Answer: A
Rationale: Cranial nerve V (Trigeminal nerve) is responsible for facial sensation and mastication. Testing facial sensation and palpating the masseter muscles assess its function. Hearing, smell, and swallowing are assessed by other cranial nerves.
What should the nurse explain about levodopa?
- A. It stimulates dopamine receptors in the basal ganglia.
- B. It promotes the release of dopamine from brain neurons.
- C. It is a precursor of dopamine that is converted to dopamine in the brain.
- D. It prevents the excessive breakdown of dopamine in the peripheral tissues.
Correct Answer: C
Rationale: Levodopa is a precursor of dopamine that crosses the blood-brain barrier
When assessing a patient's orientation, the nurse should:
- A. Ask the patient questions about their name, location, and the date.
- B. Measure the patient's temperature.
- C. Inspect the patient's skin color.
- D. Check the patient's pulse rate.
Correct Answer: A
Rationale: Orientation is assessed by asking the patient about their name, location, and the date. Temperature, skin color, and pulse rate are unrelated to orientation.
A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that suddenly started a short time ago. Assessment of the patient reveals increased blood pressure (168/94) and decreased heart rate (48/minute), diaphoreses, and flushing of the face and neck. What action should you take first?
- A. Administer the ordered acetaminophen (Tylenol).
- B. Check the Foley tubing for kinks or obstruction.
- C. Adjust the temperature in the patient's room.
- D. Notify the physician about the change in status.
Correct Answer: B
Rationale: Checking the Foley tubing is critical as it could indicate autonomic dysreflexia, a life-threatening condition in SCI patients.
A client is admitted with a head injury. To monitor hypothalamic function, the nurse should monitor what parameters?
- A. Temp and urinary output
- B. Gastric aspirate and BP
- C. Heart rate and pupillary responses
- D. Respiratory rate and skin integrity
Correct Answer: A
Rationale: The hypothalamus regulates body temperature and fluid balance, making temperature and urinary output key parameters to monitor in head injury patients. Hypothalamic dysfunction can lead to disorders like diabetes insipidus or syndrome of inappropriate antidiuretic hormone (SIADH), affecting fluid balance and temperature regulation.