Nokea
Mr. Singer will be taking aspirin and prednisone for his rheumatoid arthritis upon discharge from the hospital. Mr. Singer should be taught to contact his physician immediately if which of the following occurs?
- A. Tarry stools
- B. Ringing in his ears
- C. Warm, swollen joints
- D. Fluid retention
Correct Answer: A
Rationale: Tarry stools indicate gastrointestinal bleeding, a potential side effect of aspirin.
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A patient is admitted with an open fracture of the tibia following a bicycle accident. During assessment of the patient, what specifically should the nurse question the patient about?
- A. Any previous injuries to the leg
- B. The status of tetanus immunization
- C. The use of antibiotics in the last month
- D. Whether the injury was exposed to dirt or gravel
Correct Answer: B
Rationale: Tetanus prophylaxis is crucial in open fractures due to the risk of contamination.
Use of the Glasgow Coma Scale (GCS) provides relatively objective measurement of the Level of Consciousness (LOC). The three functions assessed are:
- A. Pupil reaction, orientation, and sensation
- B. Verbal response, eye opening, and motor response
- C. Eye opening, motor response, and sensation
- D. Verbal response, pupil reaction, and motor response
Correct Answer: B
Rationale: The Glasgow Coma Scale (GCS) assesses three functions: eye opening, verbal response, and motor response. It is used to evaluate the level of consciousness in patients with brain injuries. Pupil reaction, orientation, and sensation are not part of the GCS.
What is a nursing intervention that is appropriate for the patient with a nursing diagnosis of anxiety related to lack of knowledge of the etiology and treatment of headache?
- A. Help the patient to examine lifestyle patterns and precipitating factors.
- B. Administer medications as ordered to relieve pain and promote relaxation.
- C. Provide a quiet
- D. dimly lit environment to reduce stimuli that increase muscle tension and anxiety.
Correct Answer: C
Rationale: Reducing stimuli in the environment helps alleviate anxiety and muscle tension
The ability that humans have to perform very skilled movements such as writing is controlled by the:
- A. Basal ganglia.
- B. Corticospinal tract.
- C. Spinothalamic tract.
- D. Extrapyramidal tract.
Correct Answer: B
Rationale: The correct answer is B: Corticospinal tract. The corticospinal tract is responsible for controlling voluntary skilled movements like writing. It carries motor commands from the primary motor cortex to the spinal cord, enabling precise movements of the hands and fingers. The basal ganglia (A) are involved in motor planning and coordination but not direct control of skilled movements. The spinothalamic tract (C) is responsible for transmitting sensory information related to pain and temperature, not motor control. The extrapyramidal tract (D) is involved in involuntary movements and posture regulation, not skilled movements like writing.
A patient is admitted to the emergency department with a spinal cord injury at the level of T2. Which finding is of most concern to the nurse?
- A. SpO2 of 92%
- B. Heart rate of 42 bpm
- C. Blood pressure of 88/60 mm Hg
- D. Loss of motor and sensory function in arms and legs
Correct Answer: B
Rationale: Bradycardia is concerning due to autonomic dysreflexia.