Nokea
How can the nurse examine the client for stiffness and rigidity of the neck?
- A. By positioning the client flat on the bed for at least three hours.
- B. By moving the head and chin of the client towards the chest.
- C. By asking the client to bend and pick up small and large objects on the floor.
- D. By introducing a painful stimulus on the neck.
Correct Answer: B
Rationale: This movement checks for neck stiffness indicative of neurological issues.
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Mrs. Rollo has been instructed to check her urine with a multiple test stick. For which abnormal finding should she be particularly alert and report to you when the test is positive?
- A. Glucose
- B. pH of 5
- C. Protein
- D. Ketones
Correct Answer: C
Rationale: Proteinuria can indicate kidney damage, a potential side effect of gold therapy.
A previously healthy 26-year-old male is brought to the emergency department due to muscle weakness. He reports mild weakness in his legs that has progressively worsened over a few days to the point that he can barely move his legs. He has some numbness in his legs and his arms feel weak. He has recently recovered from a respiratory infection. 1/5 muscle strength is noted throughout the lower extremities, as well as absent patellar and ankle reflexes. 3 to 4-/5 muscle strength is appreciated throughout his upper extremities. A lumbar puncture is performed, which shows the following: Cell count: 4 cells/mm3, Glucose: 67 mg/dL, Protein: 187 mg/dL Gram stain: no organisms Spirometry is performed, which shows a forced vital capacity of 0.85 L. Which of the following is the best next step in management?
- A. Intravenous (IV) immunoglobulin
- B. Intubation
- C. IV corticosteroids
- D. Immunomodulating agent
Correct Answer: B
Rationale: The patient's presentation of rapidly progressive weakness, areflexia, and elevated cerebrospinal fluid protein with normal cell count (albuminocytologic dissociation) is classic for Guillain-Barre syndrome (GBS). The forced vital capacity of 0.85 L indicates respiratory failure, necessitating immediate intubation to protect the airway and provide mechanical ventilation. Intravenous immunoglobulin and plasma exchange are treatments for GBS but are secondary to securing the airway in this critically ill patient.
Dysdiadochokinesia refers to ___________.
- A. inability to walk
- B. excessive movements of the appendages
- C. ignoring one side of the body opposite brain damage
- D. inability to do alternating movements
Correct Answer: D
Rationale: Dysdiadochokinesia is the inability to perform rapid alternating movements, such as pronation and supination of the hand. It is often a sign of cerebellar dysfunction, which affects motor coordination.
When is a fat embolism most likely to occur?
- A. 24 to 48 hours following a fractured tibia
- B. 36 to 72 hours following a skull fracture
- C. 4 to 5 days following a fractured femur
- D. 5 to 6 days following a pelvic fracture
Correct Answer: A
Rationale: Fat embolism is most common after tibial fractures within 24-48 hours.
The male client diagnosed with multiple sclerosis states he has been investigating alternative therapies to treat his disease. Which intervention is most appropriate by the nurse?
- A. Encourage the therapy if it is not contraindicated by the medical regimen.
- B. Tell the client only the health-care provider should discuss this with him.
- C. Ask how his significant other feels about this deviation from the medical regimen.
- D. Suggest the client research an investigational therapy instead.
Correct Answer: A
Rationale: Encouraging alternative therapies that are safe and not contraindicated can empower the client and support their autonomy in managing their condition.