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Priority Decision: A patient is admitted to the emergency department with a possible cervical spinal cord injury following an automobile crash. During admission of the patient, what is the highest priority for the nurse?
- A. Maintaining a patent airway
- B. Maintaining immobilization of the cervical spine
- C. Assessing the patient for head and other injuries
- D. Assessing the patient's motor and sensory function
Correct Answer: B
Rationale: Immobilization prevents further injury.
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The nurse is reviewing the results of a patient's diagnostic tests which show changes in nerve insulation. What structure should the nurse explain to the patient that electrically insulates neurons?
- A. Astrocytes
- B. Gray matter
- C. Interneurons
- D. Myelin sheath
Correct Answer: D
Rationale: The myelin sheath is a phospholipid layer that electrically insulates neurons, allowing for faster transmission of nerve impulses. Astrocytes are a type of neuroglial cell, gray matter contains cell bodies, and interneurons facilitate communication within the central nervous system. The myelin sheath's role in nerve function is critical for understanding neurological disorders.
To assess cranial nerve VIII (Vestibulocochlear nerve), the nurse should:
- A. Perform a hearing test and assess balance.
- B. Evaluate the patient's ability to swallow.
- C. Inspect the patient's throat.
- D. Palpate the patient's neck.
Correct Answer: A
Rationale: Cranial nerve VIII (Vestibulocochlear nerve) is responsible for hearing and balance. A hearing test and balance assessment evaluate its function. Swallowing, throat inspection, and neck palpation are unrelated.
A Neurological disorder that is characterised by impairments in motor performance and coordination are known as
- A. Dyspraxia
- B. Apraxia
- C. Anapraxia
- D. Amotoria
Correct Answer: B
Rationale: Apraxia is a neurological disorder that affects the ability to perform purposeful movements, despite having the physical ability and desire to do so. Individuals with apraxia may struggle with tasks like dressing, cooking, or using tools. This condition is often caused by damage to the parietal lobe or other areas of the brain involved in motor planning and execution.
A client with rheumatoid arthritis taking hydroxychloroquine (Plaquenil) should be taught that, because of this drug therapy, he should
- A. expect relief of pain and inflammation within 1-2 weeks
- B. have an eye examination every 4-6 months
- C. take the medication before bedtime
- D. be alert for development of a skin rash
Correct Answer: B
Rationale: Hydroxychloroquine can cause retinal damage, requiring regular eye exams.
The olfactory area is found within the:
- A. occipital lobe
- B. temporal lobe
- C. frontal lobe
- D. parietal lobe
Correct Answer: B
Rationale: The olfactory area, responsible for the sense of smell, is located in the temporal lobe of the brain. The occipital, frontal, and parietal lobes have different functions, and the pyramidal tract is involved in motor control. Therefore, B is the correct answer.