Nokea
Mrs. Go a 75-year old female suffered a fdall and is diagnosed with a herniated nucleus pulposus at the C4-C5 interspace, and a second st the C5-C6 interspace.Which of the following findings would the nurse expect to discover during the assessment?
- A. constant, throbbing headaches
- B. clonus in the lower extremities
- C. Numbness of the face
- D. pain in the scapular region
Correct Answer: D
Rationale: A herniated nucleus pulposus at the C4-C5 and C5-C6 interspace typically results in neck and shoulder pain, which can radiate to the scapular region. The herniation at these levels can cause irritation or compression of the cervical nerve roots leading to pain, numbness, tingling, or weakness in the affected areas. Constant, throbbing headaches are not typically associated with this specific diagnosis. Clonus in the lower extremities and numbness of the face are also not common findings related to herniated nucleus pulposus at the cervical spine levels mentioned.
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While managing a client after a medical or surgical procedure for bladder stones, for what rise in the temperature should the nurse notify the physician?
- A. When the temperature rises above 101F
- B. When the temperature rises above 100F
- C. When the temperature rises above 102F
- D. When the temperature rises above 99F
Correct Answer: C
Rationale: A rise in temperature is concerning after a medical or surgical procedure as it can indicate infection or other complications. A temperature above 102F is typically considered a significant fever, especially in the postoperative period. It is essential to notify the physician promptly to assess the patient's condition and provide appropriate interventions to address the underlying cause of the fever.
Which is now referred to as the "new morbidity"?
- A. Limitations in the major activities of daily living
- B. Unintentional injuries that cause chronic health problems
- C. Discoveries of new therapies to treat health problems
- D. Behavioral, social, and educational problems that alter health
Correct Answer: D
Rationale: The term "new morbidity" is now used to describe the impact of behavioral, social, and educational factors on health outcomes. This concept acknowledges that health is not solely determined by physical health conditions but also by one's behaviors, social circumstances, and education levels. Factors such as smoking, substance abuse, stress, lack of education, poverty, and social inequalities can significantly influence an individual's health. Recognizing and addressing these non-traditional health determinants are crucial in promoting overall health and well-being.
Which of the following responses indicates sympathetic nervous system function?
- A. Tachycardia, dilated pupils
- B. Hypoglycaemia, headache
- C. Increased peristalsis, abdominal cramping
- D. Pupil constriction, bronchoconstriction
Correct Answer: A
Rationale: The sympathetic nervous system is responsible for the body's "fight or flight" response. Tachycardia (increased heart rate) and dilated pupils are classic responses of the sympathetic nervous system activation during times of stress or danger. These physiological responses prepare the body for action, such as running away from a threat.
In planning safe care for the older adult, which of the ff. conditions does the nurse recognize would not cause visual problems?
- A. Glaucoma
- B. Macular degeneration
- C. Cataracts
- D. Arcus senilis
Correct Answer: D
Rationale: Arcus senilis is a condition characterized by a white or gray ring forming around the cornea and does not typically cause visual problems. It is a common and benign condition often seen in older adults. On the other hand, glaucoma, macular degeneration, and cataracts are all eye conditions that can significantly affect vision and lead to visual impairments in older adults. Therefore, in planning safe care for the older adult, the nurse should recognize that Arcus senilis would not cause visual problems unlike the other conditions mentioned.
Sunshine, age 13, has had a lumbar puncture to examine the CSF to determine if bacterial infection exists. The best position to keep her in after the procedure is:
- A. Prone for two hours to prevent aspiration, should she vomit.
- B. Semi-Fowler's so she can watch TV for five hours and be entertained.
- C. Supine for several hours, to prevent a headache.
- D. On her right sides to encourage return of CSF
Correct Answer: C
Rationale: The best position to keep Sunshine in after a lumbar puncture is in the supine position for several hours. This position helps prevent a post-lumbar puncture headache, which is a common complication of the procedure. Keeping Sunshine supine helps reduce the chances of leaking CSF and minimizes the risk of developing a headache due to decreased CSF pressure. Additionally, it is vital to encourage increased fluid intake post-procedure to help replenish the lost CSF and prevent dehydration.