Nokea
In helping Mr. Hall to maintain proper body alignment in bed to prevent dislocation of the prosthetic head and hip contracture, the nurse should assist the patient to lie
- A. straight in bed alternating head position from flat to 30° elevation and left leg abducted
- B. diagonally toward the right side of the bed with legs together
- C. flat on back in bed for first 48 hours with legs adducted
- D. on the right side only with the left leg in front of the right leg
Correct Answer: A
Rationale: This position minimizes stress on the new hip joint.
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What do we call the layer of fatty tissue surrounding the axon of some neurons?
- A. cutaneous coating
- B. myelin sheath
- C. dendritic barrier
- D. synaptic sleeve
Correct Answer: B
Rationale: The myelin sheath is a layer of fatty tissue that surrounds the axons of some neurons, providing insulation and increasing the speed of electrical signal transmission. Myelin is produced by glial cells, such as oligodendrocytes in the central nervous system and Schwann cells in the peripheral nervous system. Damage to the myelin sheath, as seen in conditions like multiple sclerosis, can impair neural communication and lead to neurological symptoms.
When assessing a patient's response to stimuli, the nurse should:
- A. Observe for changes in the patient's reaction to verbal and physical stimuli.
- B. Measure the patient's heart rate.
- C. Inspect the patient's skin for lesions.
- D. Check the patient's blood pressure.
Correct Answer: A
Rationale: Response to stimuli is assessed by observing the patient's reaction to verbal and physical stimuli. Heart rate, skin lesions, and blood pressure are unrelated to this assessment.
The cerebellum, ________ portion of the brain, is located below the occipital lobes of the cerebrum.
- A. the largest
- B. the second largest
- C. the third largest
- D. the smallest
Correct Answer: B
Rationale: The cerebellum is the second largest portion of the brain, located below the occipital lobes of the cerebrum. It plays a crucial role in coordinating voluntary movements, balance, and posture. While the cerebrum is the largest part of the brain, the cerebellum is smaller but still significant in size and function. Therefore, the second largest is the correct answer.
What is the major focus for care today for a patient who is 1 day post-operative after a left below-the-knee amputation?
- A. To attain pain control for phantom pain.
- B. To monitor for signs of sufficient tissue perfusion.
- C. To assist the patient to ambulate as soon as possible.
- D. To elevate the residual limb when the patient is supine.
Correct Answer: B
Rationale: Ensuring adequate tissue perfusion is critical in the immediate post-operative period to prevent complications.
A patient with a fractured femur experiences the complication of malunion. The nurse recognizes that what happens with this complication?
- A. The fracture heals in an unsatisfactory position.
- B. The fracture fails to heal properly despite treatment.
- C. Fracture healing progresses more slowly than expected.
- D. Loss of bone substances occurs as a result of immobilization.
Correct Answer: A
Rationale: Malunion refers to a healed fracture in an incorrect alignment or position.