Nokea
Meningeal syndrome suggests any of the following, EXCEPT:
- A. neck stiffness
- B. headache
- C. photophobia
- D. Babynsky response
Correct Answer: D
Rationale: Babinski's response is the correct answer because it is a pathological reflex indicative of upper motor neuron damage, not meningeal irritation. Meningeal syndrome, which includes neck stiffness, headache, and photophobia, is typically caused by inflammation of the meninges, as seen in meningitis or subarachnoid hemorrhage.
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Which of the following measures should be taken by the nurse to help relieve edema in a client with tissue injury?
- A. Massaging the swollen body part
- B. Taking a prescribed analgesic
- C. Applying a cold pack to the swollen body part
- D. Keeping the swollen body part above the level of the heart
Correct Answer: D
Rationale: Elevating the affected area helps reduce edema by improving venous return.
Which of the following diets will provide the greatest symptomatic relief for Mr. Sands?
- A. Clear liquid diet
- B. Soft diet with frequent meals
- C. Regular diet
- D. High-residue diet
Correct Answer: B
Rationale: A soft diet with frequent meals reduces strain on the esophagus and stomach.
The presence of hemianesthesia, hemianopia & sensory hemiataxia suggests damage to the following:
- A. internal capsule
- B. thalamus opticus
- C. spinal cord
- D. black substance
Correct Answer: B
Rationale: Thalamus opticus is the correct answer because it is a key relay station for sensory information, including pain, temperature, and visual signals. Damage to the thalamus can result in hemianesthesia (sensory loss on one side), hemianopia (visual field loss on one side), and sensory hemiataxia (loss of coordination on one side) due to disrupted sensory processing.
A patient says, I feel detached and weird all the time, like I'm looking at life through a cloudy window. Everything seems unreal. These feelings really interfere with my work and study. Which term should the nurse use to document this complaint?
- A. Depersonalization
- B. Hypochondriasis
- C. Dissociation
- D. Malingering
Correct Answer: A
Rationale: Correct Answer: A. Depersonalization
Rationale:
1. Depersonalization involves feeling detached from oneself or reality, as described by the patient.
2. The patient's description of feeling like they are looking through a cloudy window aligns with depersonalization symptoms.
3. Interference with work and study suggests significant distress, a common feature of depersonalization disorder.
Summary of other choices:
B. Hypochondriasis: Involves excessive worry about having a serious illness, which is not indicated in the patient's complaint.
C. Dissociation: While depersonalization is a type of dissociative symptom, it specifically refers to feeling detached and unreal, not necessarily a broader dissociative disorder.
D. Malingering: Involves feigning or exaggerating symptoms for secondary gain, which is not evident in the patient's genuine distress and impairment.
An appropriate nursing intervention for this patient?
- A. Post clocks and calendars in the patient's environment.
- B. Establish and consistently follow a daily schedule with the patient.
- C. Monitor the patient's activities to maintain a safe patient environment.
- D. Stimulate thought processes by asking the patient questions about recent activities.
Correct Answer: B
Rationale: Consistent schedules help orient patients with dementia