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During the physical assessment, the nurse recalls that the areas most frequently affected by multiple sclerosis are the:
- A. Lateral, 3rd and 4th ventricles
- B. Pons medulla and cerebral peduncles
- C. Optic nerve and chiasm
- D. Above areas
Correct Answer: C
Rationale: Rationale for Choice C (Correct Answer):
1. Multiple sclerosis (MS) commonly affects the optic nerve and chiasm.
2. MS is characterized by demyelination of nerves, leading to visual disturbances.
3. Optic nerve involvement results in vision problems, such as blurred vision.
4. Chiasm involvement can cause visual field deficits and color perception changes.
Summary of Other Choices:
A: Lateral, 3rd, and 4th ventricles - Incorrect. MS primarily affects the central nervous system, not ventricles.
B: Pons, medulla, and cerebral peduncles - Incorrect. While these areas are part of the brainstem, they are not commonly affected in MS.
D: Above areas - Incorrect. This choice is vague and does not specify any specific areas affected by MS.
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A patient’s son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do?
- A. Individualize the care plan only according to the patient’s needs.
- B. Request that the son leave at bedtime, so the patient can rest.
- C. Suggest that a female member of the family stay with the patient.
- D. Involve the son in the plan of care as much as possible.
Correct Answer: D
Rationale: The correct answer is D: Involve the son in the plan of care as much as possible. This is important for several reasons. Firstly, involving the son promotes family-centered care, which can improve patient outcomes. Secondly, the son may provide valuable insights into the patient's preferences and needs. Thirdly, it can help reduce the patient's confusion by providing familiar support. Option A is incorrect as it disregards the potential benefits of involving family members. Option B is incorrect as it focuses on the patient's rest without considering the emotional support the son may provide. Option C is incorrect as it assumes the gender of the family member matters more than their relationship to the patient.
The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask?
- A. “Is there anything that you are stressed about right now that I should know?”
- B. “What reasons do you think are contributing to your fatigue?”
- C. “What are your normal work hours?”
- D. “Are you sleeping 8 hours a night?”
Correct Answer: B
Rationale: The correct answer is B because it encourages the patient to reflect on their own thoughts and identify potential causes of their fatigue. It allows the patient to express their own insights and helps the nurse understand the underlying reasons for the fatigue. Choice A focuses on stress, which may not be the main cause of fatigue. Choice C is irrelevant to exploring the fatigue further. Choice D assumes that lack of sleep is the main issue, which may not be the case for the patient.
A nurse identifies Fatigue as a health problem and nursing diagnosis for a client receiving home care for metastatic cancer. What statement or question would be best to validate this client problem?
- A. I have assessed you and find you are fatigued.
- B. I analyzed and interpreted your information as fatigue.
- C. Why are you so tired all the time?
- D. I think fatigue is a problem for you. Do you agree?
Correct Answer: D
Rationale: The correct answer is D because it involves collaboration with the client to validate the identified health problem. By asking the client directly if they agree that fatigue is a problem for them, it promotes client-centered care and empowers the client in their own care. Choice A is incorrect as it assumes the nurse's assessment is enough to confirm fatigue. Choice B is incorrect as it focuses on the nurse's analysis rather than the client's experience. Choice C is incorrect because it is a closed-ended question that may not encourage open communication or validation from the client.
The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?
- A. The nurse provides assistance while the patient is walking in the hallways.
- B. The patient is able to ambulate in the hallway with crutches.
- C. The patient will deny pain while walking in the hallway.
- D. The patient’s level of mobility will improve.
Correct Answer: B
Rationale: The correct answer is B because the patient being able to ambulate in the hallway with crutches indicates that the expected outcome of improved physical mobility due to the fractured leg has been met. This demonstrates progress towards independence and recovery.
A is incorrect because the patient still requires assistance, indicating dependency. C is incorrect because denial of pain does not necessarily indicate improved physical mobility. D is incorrect because it is too general and does not directly show achievement of the specific goal related to physical mobility.
Mr. RR is admitted to the hospital with a diagnosis of brain tumor. Mr. RR’s doctor is very much concerned about the possibility of increased intracranial pressure. The following is the most reliable index of cerebral state:
- A. Level of consciousness
- B. Unilateral papillary dilatation
- C. Increased systolic BP
- D. Decreased pulse pressure
Correct Answer: A
Rationale: Step 1: Level of consciousness is the most reliable index of cerebral state because it directly reflects the functioning of the brain. Changes in consciousness can indicate alterations in cerebral perfusion and potential increases in intracranial pressure.
Step 2: Unilateral papillary dilatation may suggest an increase in intracranial pressure, but it is not as reliable as level of consciousness in assessing overall cerebral state.
Step 3: Increased systolic blood pressure can occur due to various reasons and may not specifically indicate changes in intracranial pressure.
Step 4: Decreased pulse pressure may be related to factors such as hypovolemia or cardiac conditions, but it is not a direct indicator of cerebral state or intracranial pressure.