Nokea
In assessing Bob, which of the following complaints would indicate radial nerve injury?
- A. Pain at the fracture site
- B. Inability to extend the wrist
- C. Inability to flex the elbow
- D. Paralysis of the hand and forearm
Correct Answer: B
Rationale: The radial nerve primarily controls wrist extension; inability to extend the wrist indicates radial nerve damage.
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You are mentoring a student nurse in the intensive care unit (ICU) while caring for a patient with meningococcal meningitis. Which action by the student requires that you intervene immediately?
- A. The student enters the room without putting on a mask and gown.
- B. The student instructs the family that visits are restricted to 10 minutes.
- C. The student gives the patient a warm blanket when he says he feels cold.
- D. The student checks the patient's pupil response to light every 30 minutes.
Correct Answer: A
Rationale: Infection control measures are critical in preventing the spread of meningococcal meningitis.
What is the purpose of performing the Romberg test?
- A. To assess the patient's balance and proprioception.
- B. To measure the patient's blood pressure.
- C. To inspect the patient's skin color.
- D. To check the patient's hearing ability.
Correct Answer: A
Rationale: The Romberg test evaluates balance and proprioception by having the patient stand with eyes closed. Blood pressure, skin color, and hearing are unrelated to this test.
The presence of Bell's palsy suggests damage to the following cranial nerve:
- A. facial
- B. optic
- C. olfactory
- D. vestibular
Correct Answer: A
Rationale: Facial nerve is the correct answer because Bell's palsy is a condition characterized by the sudden weakness or paralysis of the facial muscles on one side of the face due to inflammation or damage to the facial nerve (cranial nerve VII). This results in symptoms such as drooping of the mouth, inability to close the eye, and loss of facial expression.
What should the nurse include in discharge instructions for the patient following a hip prosthesis with a posterior approach?
- A. Restrict walking for 2 to 3 months.
- B. Take a bath rather than a shower to prevent falling.
- C. Keep the leg internally rotated while sitting and standing.
- D. Have a family member put on the patient's shoes and socks.
Correct Answer: D
Rationale: Family assistance minimizes strain on the hip.
Benzodiazepine medication is being used to help manage this patient's behavior?
- A. Sertraline (Zoloft)
- B. Donepezil (Aricept)
- C. Lorazepam (Ativan)
- D. Risperidone (Risperdal)
Correct Answer: C
Rationale: Lorazepam is a benzodiazepine used for agitation