Nokea
During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute?
- A. Limiting conversation with the child
- B. Keeping extraneous noise to a minimum
- C. Allowing the child to play in the bathtub
- D. Performing treatments quickly
Correct Answer: B
Rationale: Reducing extraneous noise and stimuli is crucial in managing a child with meningitis. The inflammation of the meninges increases sensitivity to light and sound, exacerbating irritability and restlessness. A calm, quiet environment helps minimize discomfort and supports recovery.
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Which of the following symptoms should the nurse closely monitor for in a client with a compartment syndrome in the upper arm?
- A. Epicondylitis
- B. Carpal tunnel syndrome
- C. Volkmann's contracture
- D. Ganglion cyst
Correct Answer: C
Rationale: Volkmann's contracture is a serious complication of compartment syndrome.
Chemicals called ________ are stored in neurons and released when the cell is stimulated by a signal.
- A. toxins
- B. cytokines
- C. chemokines
- D. neurotransmitters
Correct Answer: D
Rationale: The correct answer is D: neurotransmitters. Neurons store and release neurotransmitters in response to signals to communicate with other neurons or target cells. Neurotransmitters play a crucial role in transmitting signals across synapses. Toxins (A) are harmful substances, not involved in neuronal communication. Cytokines (B) and chemokines (C) are signaling molecules involved in immune responses, not neuronal communication. Therefore, the correct choice is neurotransmitters.
A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient's deep tendon reflexes?
- A. Reflexes will be normal.
- B. Reflexes cannot be elicited.
- C. All reflexes will be diminished but present.
- D. Some reflexes will be present, depending on the area of injury.
Correct Answer: A
Rationale: The correct answer is A: Reflexes will be normal. In a patient with a head injury resulting from trauma and no other injuries, deep tendon reflexes are typically unaffected by the injury. The brain stem controls deep tendon reflexes, and since there are no other injuries, the reflexes should remain normal. Choices B, C, and D are incorrect because they do not align with the typical response of deep tendon reflexes in a head injury without other injuries. Choice B stating that reflexes cannot be elicited is incorrect as deep tendon reflexes are usually intact in this scenario. Choice C suggesting all reflexes will be diminished but present is incorrect as deep tendon reflexes are typically not affected by head injuries. Choice D stating that some reflexes will be present depending on the area of injury is incorrect because deep tendon reflexes are primarily controlled by the brain stem, which is not directly affected in this situation.
The following signs occur in ipsilateral interruption of the cervical sympathetic trunk:
- A. enophthalmos
- B. ptosis
- C. vasodilatation in the skin of the face
- D. All above
Correct Answer: D
Rationale: Interruption of the cervical sympathetic trunk leads to Horner's syndrome, characterized by ipsilateral ptosis (drooping eyelid), miosis (pupil constriction), and anhidrosis (lack of sweating). Enophthalmos (sunken eye) and vasodilatation in the facial skin may also occur due to loss of sympathetic tone.
A patient with a fractured tibia accompanied by extensive soft tissue damage initially has a splint applied and held in place with an elastic bandage. What early sign should alert the nurse that the patient is developing compartment syndrome?
- A. Paralysis of the toes
- B. Absence of peripheral pulses
- C. Distal pain unrelieved by opioid analgesics
- D. Skin over the injury site is blanched when the bandage is removed
Correct Answer: C
Rationale: Unrelieved pain despite opioids is a hallmark of compartment syndrome.