Nokea
Priority Decision: Following change-of-shift handoff, which patient should the nurse assess first?
- A. A 58-year-old male experiencing phantom pain and requesting analgesic
- B. A 72-year-old male being transferred to a skilled nursing unit following repair of a hip fracture
- C. A 25-year-old female in left leg skeletal traction asking for the weights to be lifted for a few minutes
- D. A 68-year-old male with a new lower leg cast complaining that the cast is too tight and he cannot feel his toes
Correct Answer: D
Rationale: Cast tightness and loss of sensation indicate potential neurovascular compromise.
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A patient with a fractured right hip has an anterior open reduction and internal fixation of the fracture. What should the nurse plan to do postoperatively?
- A. Get the patient up to the chair on the first postoperative day.
- B. Position the patient only on the back and the unoperative side.
- C. Keep the leg abductor pillow on the patient even when bathing.
- D. Ambulate the patient with partial weight bearing by discharge.
Correct Answer: C
Rationale: Using an abductor pillow maintains proper alignment.
Which observation of the patient made by the nurse is most indicative of Parkinson's disease?
- A. Large
- B. embellished handwriting
- C. Weakness of one leg resulting in a limping walk
- D. Difficulty rising from a chair and beginning to walk
Correct Answer: C
Rationale: Difficulty initiating movement is characteristic of Parkinson's disease
A graduate nurse is taking a test on neurological conditions. Which of the following nursing interventions is used as a gastrointestinal preventative measure for the client with intracranial pressure?
- A. Insertion of an NG tube
- B. Administration of a histamine antagonist (Pepcid)
- C. Sips of clear fluid
- D. Insertion of a rectal tube
Correct Answer: B
Rationale: Histamine antagonists help prevent stress ulcers in clients with intracranial pressure.
Trigeminal nerve impairment produces the following symptoms:
- A. plegia in half of the face
- B. ache paroxysm in half of the face
- C. disturbance of swallowing
- D. ache in half of the head
Correct Answer: B
Rationale: Ache paroxysm in half of the face is the correct answer because the trigeminal nerve is responsible for sensory innervation of the face and motor control of the muscles of mastication. Damage to this nerve, as seen in trigeminal neuralgia, results in severe, episodic facial pain.
The patient is diagnosed with torticollis. What should the nurse be prepared to provide for the patient?
- A. An immobilizer to hold the bones in place
- B. Exercises to increase the strength of the muscles
- C. A pillow to use to support the knees while sleeping
- D. Enough pillows to support the patient's head comfortably
Correct Answer: B
Rationale: Exercises help restore muscle balance.