Nokea
The disturbance of purposive movement in absence of paresis & dyscoordination suggests the presence of the following:
- A. dyslexia
- B. dysgnosia
- C. dyspraxia
- D. dysphasia
Correct Answer: C
Rationale: Dyspraxia is the correct answer because it is a disorder of motor planning and execution, where the individual has difficulty performing purposeful movements despite having the physical ability and desire to do so. This condition is not due to muscle weakness or incoordination but rather to a disruption in the brain's ability to plan and execute movements.
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Which of the following is a sign of urinary retention in older adults with neurologic deficit?
- A. Amnesia
- B. Hypotension
- C. Hypertension
- D. A behavior change
Correct Answer: D
Rationale: Behavior changes, such as confusion, can indicate urinary retention.
The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits:
- A. A positive Brudzinski's sign
- B. A negative Kernig's sign
- C. Absence of nuchal rigidity
- D. A Glascow Coma Scale score of 15
Correct Answer: A
Rationale: A positive Brudzinski's sign, where flexion of the neck causes involuntary flexion of the hips and knees, is a classic sign of meningitis. Meningitis is a potential complication after craniotomy due to the breach in the protective meninges, allowing pathogens to enter the central nervous system. Other signs include fever, headache, and nuchal rigidity.
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 patient recovering from an acute exacerbation of RA tells the nurse that she is too tired to bathe. What should the nurse do for this patient?
- A. Give the patient a bed bath to conserve her energy.
- B. Allow the patient a rest period before showering with the nurse's help.
- C. Tell the patient that she can skip bathing if she will walk in the hall later.
- D. Inform the patient that it is important for her to maintain self-care activities.
Correct Answer: A
Rationale: Conserving energy is critical during flares.
A patient with Guillain-Barré syndrome asks whether he is going to die as the paralysis spreads toward his chest. In responding to the patient, what should the nurse know to be able to answer this question?
- A. Patients who require ventilatory support almost always die.
- B. Death occurs when nerve damage affects the brain and meninges.
- C. Most patients with Guillain-Barré syndrome make a complete recovery.
- D. If death can be prevented, residual paralysis and sensory impairment are usually permanent.
Correct Answer: C
Rationale: Most patients recover fully, though some may have long-term deficits.