Nokea
During the acute phase of dermatomyositis, what is an appropriate patient outcome?
- A. Relates improvement in pain
- B. Does not experience aspiration
- C. Performs active ROM four times daily
- D. Maintains absolute rest of affected joints
Correct Answer: B
Rationale: Preventing aspiration is critical in dermatomyositis.
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In the acute phase following a cerebrovascular accident, patients have a tendency to develop pressure lesions for all of the following reasons EXCEPT
- A. high degree of muscle spasticity
- B. accompanying sensory loss
- C. interference with altered autonomic reflexes
- D. diminished muscle use
Correct Answer: A
Rationale: Spasticity does not typically contribute to pressure ulcers.
The nurse notes that a patient has a history of falling. Which part of the brain should the nurse question as being affected in this patient?
- A. Medulla
- B. Cerebellum
- C. Frontal lobes
- D. Hypothalamus
Correct Answer: B
Rationale: The cerebellum is responsible for coordination, balance, and posture, making it the most likely area affected in a patient with a history of falling. The medulla regulates vital functions, the frontal lobes control voluntary movement, and the hypothalamus maintains homeostasis. The cerebellum's role in motor control is essential for assessing balance issues.
What type of diet is recommended for people with seizures or epilepsy?
- A. high carbohydrate diet
- B. fruit-only diet
- C. ketogenic diet
- D. low-fat diet
Correct Answer: C
Rationale: The ketogenic diet is a high-fat, low-carbohydrate diet that has been shown to reduce seizure frequency in some individuals with epilepsy, particularly those who do not respond well to medication. It works by altering the body's metabolism to produce ketones, which may have anticonvulsant effects.
Mrs. Aster occasionally has pain and stiffness in her hand and fingers. Which of the following nursing measures would most effectively ease her discomfort?
- A. Wrapping her hands in a heating pad
- B. Placing a hot water bottle on top of her hands
- C. Immersing her hands in comfortably hot water
- D. Extending her hands over a heat source, e.g., register or stove
Correct Answer: C
Rationale: Immersion in warm water provides even heat distribution, reducing stiffness and pain.
During care of a patient in myasthenic crisis, maintenance of what is the nurse's first priority for the patient?
- A. Mobility
- B. Nutrition
- C. Respiratory function
- D. Verbal communication
Correct Answer: C
Rationale: Respiratory function is critical in myasthenic crisis