Nokea
For which reason is the patient with suspected Guillain-Barre Syndrome (GBS) hospitalized immediately?
- A. The infection needs to be treated with IV antibiotics to prevent paralysis.
- B. The brain may swell quickly causing seizures.
- C. The disease can rapidly progress into respiratory failure.
- D. IV hydration is needed to prevent possible fatal hypotension.
Correct Answer: C
Rationale: Hospitalization is necessary for GBS patients because the disease progresses very quickly and respiratory failure may occur.
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Which aspect is the nurse assessing when asking the patient, 'Who is the president of the United States?' during a level of consciousness data collection?
- A. Orientation
- B. Memory
- C. Calculation
- D. Knowledge
Correct Answer: D
Rationale: Knowledge is tested by questions such as 'Who is the president?' or asking about current events.
Following a myelogram the nurse will include in the postprocedure care observing for which possible complication?
- A. elevation of blood pressure.
- B. urine retention.
- C. Loss of sensation in lower extremities.
- D. slurred speech.
Correct Answer: C
Rationale: Postmyelogram care includes the data collection to ensure there is no leakage of CSF, sensation and strength of the lower extremities, or headache. To avoid a headache, the patient should be flat for a few hours.
Involuntary rhythmic movement of the eyes, with oscillations that may be horizontal, vertical, or mixed movements, is called ___
Correct Answer: nystagmus
Rationale: Nystagmus is a rhythmic movement of the eyes, which may be horizontal, vertical, or mixed in directional movement. The eye movement cannot be controlled by the patient.
A family member of a patient who has just experienced a tonic-clonic seizure is concerned about the patient's deep sleep. What is this behavior called?
- A. Convalescent period
- B. Neural recovery period
- C. Sombulant period
- D. Postictal period
Correct Answer: D
Rationale: Seizures are followed by a rest period of variable length, called a postictal period.
A patient is in which stage of Alzheimer's disease when demonstrating difficulty swallowing?
- A. Pre-Alzheimer's
- B. Early
- C. Middle
- D. Late
Correct Answer: D
Rationale: The patient who demonstrates difficulty swallowing is in the late, or severe, stage.