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During a throat assessment, a healthcare provider asks a client to stick out their tongue and notices it protrudes in the midline. Which cranial nerve is being tested?
- A. Cranial nerve X
- B. Cranial nerve V
- C. Cranial nerve IX
- D. Cranial nerve XII
Correct Answer: D
Rationale: The correct answer is cranial nerve XII (hypoglossal nerve). When testing cranial nerve XII, the healthcare provider inspects the symmetry and movement of the tongue. The tongue should protrude in the midline when the client sticks it out. Cranial nerve IX (glossopharyngeal nerve) and X (vagus nerve) are tested by depressing the tongue with a blade to observe pharyngeal movement and gag reflex. Cranial nerve V (trigeminal nerve) is responsible for testing the muscles of mastication, not tongue protrusion.
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Which of the following statements is correct about Maslow's hierarchy of needs?
- A. There are psychosocial interventions that may be applicable to all of the levels.
- B. There are physical interventions that may be applicable to all of the levels.
- C. Two of the levels may require physical intervention while four of the levels may require psychosocial intervention.
- D. Four of the levels may require physical intervention, while two of the levels may require psychosocial intervention.
Correct Answer: C
Rationale: The correct statement about Maslow's hierarchy of needs is that two of the levels may require physical intervention while four of the levels may require psychosocial intervention. Maslow's theory suggests that physiological and safety needs are more basic and may require physical interventions, while social, esteem, and self-actualization needs are more psychosocial. Choices A and B are incorrect as they wrongly suggest that all levels may require only one type of intervention. Choice D is incorrect because it inaccurately represents the balance of physical and psychosocial interventions in Maslow's hierarchy of needs.
The LPN participates in a home visit for a client with Type 2 Diabetes who has been taking Metformin for 3 years. The client states that for the past 3 months, they have been trying a vegan diet and experiencing fatigue, confusion, and mood changes. What is a likely cause of the new symptoms?
- A. vitamin B12 deficiency
- B. chronic hypoglycemia
- C. vitamin D deficiency
- D. increased tolerance to Metformin
Correct Answer: A
Rationale: The correct answer is vitamin B12 deficiency. Long-term use of Metformin can lead to vitamin B12 deficiency, and a vegan diet is low in vitamin B12. Symptoms of vitamin B12 deficiency include anemia, fatigue, confusion, and mood changes. Chronic hypoglycemia is unlikely in a client with Type 2 Diabetes who has been taking Metformin as it typically causes hyperglycemia. Vitamin D deficiency usually presents with symptoms related to bones and muscles, not confusion and mood changes. Increased tolerance to Metformin does not explain the client's new symptoms, which are more indicative of a nutritional deficiency like vitamin B12.
A client has just returned from surgery where a femoral-popliteal bypass was performed. The nurse has assessed the client and is unable to feel a pulse at either the dorsalis pedis or the posterior tibial sites of the left foot. The foot feels warm, and the color is pink. What action should the nurse perform next to prevent ischemia?
- A. Notify the physician immediately
- B. Obtain a Doppler device to check for pulses, and notify the physician if they are still absent
- C. Wait 30 minutes and recheck the pulses
- D. Document the finding
Correct Answer: B
Rationale: The nurse should immediately obtain a Doppler device and recheck the pulses. The dorsalis pedis and posterior tibial pulses can be difficult to assess and might need to be verified with a Doppler device. Since the client just had surgery with a risk of arterial insufficiency, close monitoring is crucial. If pulses are not palpable, it indicates an emergent situation requiring immediate physician notification. Waiting 30 minutes before reassessment could lead to foot ischemia. While documenting findings is essential, it should follow pulse confirmation or necessary interventions to ensure the client's foot viability.
The client has an order for a 1,000 mL bag of fluids to be infused over 8 hours. What is the correct rate?
- A. 100 mL/hr
- B. 125 mL/min
- C. 125 mL/hr
- D. 80 mL/min
Correct Answer: C
Rationale: To determine the correct infusion rate, divide the total volume of fluids (1,000 mL) by the total infusion time (8 hours), resulting in a rate of 125 mL/hr. This calculation ensures the appropriate administration of fluids over the specified time period. Choice A (100 mL/hr) is incorrect as it does not match the calculated rate based on the given information. Choice B (125 mL/min) is inaccurate because the question specifies the rate in hours, not minutes. Choice D (80 mL/min) is incorrect as it provides the rate in minutes rather than hours, which is the required unit for this scenario.
A nurse assisting with data collection notes that the client's skin is very dry. The nurse documents this finding using which term?
- A. Xerosis
- B. Pruritus
- C. Seborrhea
- D. Actinic keratoses
Correct Answer: A
Rationale: Dry skin is also called xerosis. In this condition, the epidermis lacks moisture or sebum and is often marked by a pattern of fine lines, scaling, and itching. Xerosis is the correct term for very dry skin. Pruritus is the symptom of itching, an uncomfortable sensation that prompts the urge to scratch the skin, but it does not specifically refer to dry skin. Seborrhea is a skin condition characterized by overproduction of sebum, leading to excessive oiliness or dry scales, not necessarily indicating very dry skin. Actinic keratoses are sun-related skin lesions that are premalignant and not associated with dry skin.