Nokea
Regarding the cutaneous nerve supply to arm and forearm
- A. C3/4 supply pectoral and upper shoulder
- B. Branches of the brachial plexus supply arm and forearm
- C. C4/5/6/T1 supply the majority of the arm
- D. ?
Correct Answer: B
Rationale: The brachial plexus, formed from C5-T1, supplies the cutaneous innervation of the arm and forearm. Specific branches include the median, ulnar, and radial nerves.
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A client who has a musculoskeletal problem is being discharged after a few days of hospital care. Why should the nurse consider factors related to the home environment while determining a plan for the continued rehabilitation of the client?
- A. To include additional care for clients who lack the basic amenities at home.
- B. To determine the client's access to the nearest drugstore.
- C. To modify the client's living arrangements or other accommodation changes.
- D. To determine if the client would continue with the self-care.
Correct Answer: D
Rationale: Understanding the home environment ensures the client can continue their rehabilitation effectively.
The nurse is providing care for an 87-year-old woman who is recovering from a cerebral vascular accident. Which precaution should the nurse take after noting the patient has a positive Romberg test?
- A. Institute fall-risk precautions.
- B. Provide small, frequent meals.
- C. Request a footboard and splints.
- D. Darken the room and reduce stimuli.
Correct Answer: A
Rationale: A positive Romberg test indicates impaired balance and proprioception, increasing the risk of falls. Fall-risk precautions, such as using a gait belt and ensuring a safe environment, are essential. Small meals, footboards, and reducing stimuli are not directly related to balance issues.
The nurse is caring for a client with ICP. Why will the nurse position the client in bed with HOB elevated to 30 degrees?
- A. Makes it easier for the client to breathe
- B. Prevents the Valsalva maneuver
- C. Promotes venous drainage
- D. Reduces pain
Correct Answer: C
Rationale: Elevating the head of the bed to 30 degrees promotes venous drainage from the brain, reducing intracranial pressure (ICP). This position helps improve cerebral perfusion and prevents complications associated with increased ICP, such as brain herniation.
A laminectomy and spinal fusion are performed on a patient with a herniated lumbar intervertebral disc. During the postoperative period, which finding is of most concern to the nurse?
- A. Paralytic ileus
- B. Urinary incontinence
- C. Greater pain at the graft site than at the lumbar incision site
- D. Leg and arm movement and sensation unchanged from preoperative status
Correct Answer: B
Rationale: Urinary incontinence may indicate nerve damage.
A college student observes a roommate going out wearing uncharacteristically seductive clothing, returning 12 to 24 hours later, and then sleeping for 8 to 12 hours. At other times, the roommate sits on the floor speaking like a young child. Which health problem should be considered?
- A. Functional neurological (conversion) disorder
- B. Dissociative identity disorder
- C. Dissociative amnesia
- D. Body dysmorphic disorder
Correct Answer: B
Rationale: The correct answer is B: Dissociative identity disorder. The roommate displaying different behaviors indicates potential dissociation, where different identities or states of consciousness take control. Seductive clothing and extended absence may indicate a different identity, while childlike speech may suggest another identity. This pattern aligns with the criteria for dissociative identity disorder. Functional neurological disorder (Choice A) involves physical symptoms without a clear organic cause. Dissociative amnesia (Choice C) pertains to memory loss due to psychological trauma. Body dysmorphic disorder (Choice D) involves obsession with perceived flaws in physical appearance. These options do not align with the diverse behaviors and identity shifts observed in the roommate.