Nokea
Priority Decision: Twenty-four hours after a below-the-knee amputation, a patient uses the call system to tell the nurse that his dressing (a compression bandage) has fallen off. What is the first action that the nurse should take?
- A. Apply ice to the site.
- B. Cover the incision with dry gauze.
- C. Reapply the compression dressing.
- D. Elevate the extremity on a couple of pillows.
Correct Answer: B
Rationale: Dry gauze protects the wound until proper redressing.
You may also like to solve these questions
Schwann cells are one of several types of ________ cells in the nervous system.
- A. sensory
- B. motor
- C. association
- D. neuroglial
Correct Answer: D
Rationale: Schwann cells are a type of neuroglial cell found in the peripheral nervous system (PNS). They are responsible for producing myelin, which insulates axons and enhances the speed of nerve impulse transmission. Other types of neuroglial cells include astrocytes, oligodendrocytes, and microglia, each of which supports and protects neurons in different ways. Schwann cells are essential for maintaining the health and function of peripheral neurons.
A nurse is taking care of a client with ptosis (drooping) of the eyelids, difficulty chewing and swallowing, diplopia, voice weakness, masklike facial expression, and weakness of the extremities. Which of the following conditions does the nurse suspect?
- A. Parkinson's disease
- B. Extrapyramidal disorder
- C. Multiple sclerosis
- D. Myasthenia gravis
Correct Answer: D
Rationale: Myasthenia gravis presents with these symptoms, particularly muscle weakness.
Which of the following is NOT a lobe of the brain?
- A. frontal
- B. dorsal
- C. parietal
- D. temporal
Correct Answer: B
Rationale: The brain is divided into four main lobes: frontal, parietal, temporal, and occipital. The dorsal aspect refers to the upper part of the brain or spinal cord and is not a specific lobe. Each lobe has distinct functions, such as the frontal lobe's role in decision-making and the temporal lobe's involvement in hearing and language. The dorsal term is used anatomically to describe location rather than structure.
Which part of the brain has a blood-brain barrier?
- A. anterior pituitary
- B. posterior pituitary
- C. pineal body
- D. area postrema of the fourth ventricle
Correct Answer: D
Rationale: The area postrema of the fourth ventricle lacks a blood-brain barrier, allowing it to detect toxins in the blood and trigger vomiting. Other regions listed, such as the anterior pituitary and pineal body, have a blood-brain barrier.
Twenty-four hours later Bob is discharged. Which of the following statements would indicate Bob understood your teaching?
- A. Increasing pain in the arm is expected over the next 2 days but if it continues the third day I'll call the physician.
- B. If the fingers of my left hand begin to swell and are colder than those of the right hand, I'll elevate my arm above heart level and call the physician.
- C. Bleeding may appear on the cast today. I'll circle the area and if it continues to increase, I'll call the physician.
- D. I'll immobilize my left hand for 1 week, then begin active flexion-extension exercises and continue until my follow-up visit.
Correct Answer: B
Rationale: Swelling and coldness could indicate impaired circulation, necessitating immediate medical attention.