Nokea
Patients with intracerebral hemorrhage need to be observed for signs and symptoms of increased intracranial pressure. During the compensatory phase of increased intracranial pressure an initial change in vital signs includes
- A. Cheyne-Stokes respiration
- B. an increase in pupil size
- C. a rapid irregular pulse
- D. an increase in systemic blood pressure
Correct Answer: D
Rationale: Increased blood pressure is a compensatory mechanism for raised intracranial pressure.
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_______ is a disease of the myelin sheath.
- A. Leprosy
- B. Alzheimer disease
- C. Multiple sclerosis
- D. Polio
Correct Answer: C
Rationale: Multiple sclerosis (MS) is a disease that affects the myelin sheath, the protective covering of nerve fibers in the central nervous system. In MS, the immune system mistakenly attacks myelin, leading to inflammation, scarring, and impaired nerve signal transmission. Symptoms include muscle weakness, coordination problems, and cognitive difficulties. MS is a chronic condition that can significantly impact a person's quality of life.
During a follow-up visit to a patient with acute osteomyelitis treated with IV antibiotics, the home health nurse is told by the patient's wife that she can hardly get the patient to eat because his mouth is so sore. In assessing the patient's mouth, what should the nurse expect to find?
- A. A dry, cracked tongue with a central furrow
- B. White, curdlike membranous lesions of the mucosa
- C. Ulcers of the mouth and lips surrounded by a reddened base
- D. Single or clustered vesicles on the tongue and buccal mucosa
Correct Answer: B
Rationale: Candidiasis (thrush) is a common side effect of antibiotic therapy.
The nurse is caring for a patient who is scheduled for a magnetic resonance imaging (MRI) scan. What explanation should be provided to the patient and family?
- A. A scan of the brain will be done after injection of a radioisotope.
- B. An MRI uses electrodes placed on the scalp to measure activity of the brain.
- C. An MRI measures muscle contraction after stimulation by tiny needle electrodes.
- D. An MRI is a noninvasive test that uses magnetic energy to visualize internal parts.
Correct Answer: D
Rationale: An MRI is a noninvasive imaging technique that uses magnetic fields and radio waves to create detailed images of internal structures. It does not involve radioisotopes, electrodes, or needle electrodes. Providing accurate information helps the patient and family understand the procedure.
Which of the following best describes the waxy-appearing material called myelin:
- A. an outermembrane on a neuroglial cell
- B. a lipid-protein (lipoprotein) cell membrane on the outside of axons
- C. a mass of white lipid material that surrounds the cell body of a neuron
- D. a mass of white lipid material that insulates the axon of a neuron
Correct Answer: D
Rationale: Myelin is a lipid-rich substance that forms a sheath around axons, providing insulation and increasing the speed of nerve impulse transmission. It does not surround the cell body or dendrites, making D the correct answer.
To preserve function and the ability to perform activities of daily living (ADLs), what should the nurse teach the patient with OA?
- A. Avoid exercise that involves the affected joints.
- B. Plan and organize task performance to be less stressful to joints.
- C. Maintain normal activities during an acute episode to prevent loss of function.
- D. Use mild analgesics to control symptoms when performing tasks that cause pain.
Correct Answer: B
Rationale: Task planning minimizes joint stress.