Nokea
Following a T2 spinal cord injury, the patient develops paralytic ileus. While this condition is present, what should the nurse anticipate that the patient will need?
- A. IV fluids
- B. Tube feedings
- C. Parenteral nutrition
- D. Nasogastric suctioning
Correct Answer: A
Rationale: IV fluids maintain hydration during ileus.
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Nurse Thompson is reviewing the neurological assessment of Mr. Johnson, a 70-year-old patient who exhibits tremors and slow movements. She recalls that these symptoms are often linked to a specific neurological disorder characterized by reduced dopamine levels due to the loss of pigmented neurons in the substantia nigra region of the basal ganglia. Which disease does Nurse Thompson recognize as associated with these findings?
- A. Multiple sclerosis.
- B. Huntington's disease.
- C. Creutzfeldt-Jakob's disease.
- D. Parkinson's disease.
Correct Answer: D
Rationale: Parkinson's disease is characterized by the loss of dopaminergic neurons in the substantia nigra, leading to tremors, bradykinesia, and rigidity.
An action potential:
- A. is essential for nerve impulse propagation
- B. involves the influx of negative ions to depolarize the membrane
- C. involves the outflux of negative ions to depolarize the membrane
- D. involves the outflux of positive ions to depolarize the membrane
Correct Answer: A
Rationale: An action potential is essential for nerve impulse propagation, as it is the electrical signal that travels along the neuron. It involves the influx of positive sodium ions to depolarize the membrane, not negative ions or potassium ion movements. Therefore, A is the correct answer.
A 70-year-old alcoholic patient with acute lethargy, confusion, and incontinence is admitted to the hospital ED. His wife tells you that he fell down the stairs about a month ago, but 'he didn't have a scratch afterward.' She feels that he has become gradually less active and sleepier over the last 10 days or so. Which of the following collaborative interventions will you implement first?
- A. Place on the hospital alcohol withdrawal protocol.
- B. Transfer to radiology for a CT scan.
- C. Insert a retention catheter to straight drainage.
- D. Give phenytoin (Dilantin) 100 mg PO.
Correct Answer: B
Rationale: A CT scan is needed to rule out a subdural hematoma, which could explain the symptoms.
A client is monitored for complications after having surgery to repair a fracture. Which of the following symptoms would indicate an arterial obstruction in the affected area?
- A. Rapid capillary refill
- B. Warm skin
- C. Cool skin
- D. Numbness
Correct Answer: C
Rationale: Cool skin suggests reduced blood flow, indicating arterial obstruction.
Which test evaluates a patient's coordination and balance?
- A. The finger-to-nose and heel-to-shin tests.
- B. The Snellen chart test for visual acuity.
- C. The Rinne and Weber tests for hearing.
- D. The Romberg test for proprioception.
Correct Answer: A
Rationale: The finger-to-nose and heel-to-shin tests assess coordination and balance. The Snellen chart tests vision, the Rinne and Weber tests assess hearing, and the Romberg test evaluates proprioception.