Nokea
The following conditions can affect the pupil size:
- A. iris colour
- B. fatigue
- C. exercise
- D. all above
Correct Answer: D
Rationale: Pupil size is influenced by factors such as iris color (darker irises may have smaller pupils), fatigue (pupils constrict with tiredness), and exercise (pupils dilate during physical activity). These changes are mediated by the autonomic nervous system.
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What could the nurse delegate to unlicensed assistive personnel (UAP)?
- A. Complete the admission assessment.
- B. Explain the call system to the patient.
- C. Obtain the suction equipment from the supply cabinet.
- D. Place a padded tongue blade on the wall above the patient's bed.
Correct Answer: C
Rationale: Obtaining equipment is a task that can be delegated to UAP
In assessing Bob, which of the following complaints would indicate radial nerve injury?
- A. Pain at the fracture site
- B. Inability to extend the wrist
- C. Inability to flex the elbow
- D. Paralysis of the hand and forearm
Correct Answer: B
Rationale: The radial nerve primarily controls wrist extension; inability to extend the wrist indicates radial nerve damage.
A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain that is related to these findings would concern the nurse?
- A. Thalamus
- B. Brainstem
- C. Cerebellum
- D. Extrapyramidal tract
Correct Answer: C
Rationale: The correct answer is C: Cerebellum. The cerebellum is responsible for coordinating voluntary movements, balance, and posture. Damage to the cerebellum can result in symptoms like unsteadiness and difficulty maintaining balance. The thalamus (A) is involved in relaying sensory and motor signals but is not directly related to balance. The brainstem (B) plays a role in basic life functions like breathing and heart rate, not balance. The extrapyramidal tract (D) is involved in regulating motor activities but is not primarily responsible for balance control.
The patient has a burning, sharp pain on the sole of the foot, especially in the morning. The nurse knows that this describes what common musculoskeletal problem?
- A. Pes planus
- B. Tenosynovitis
- C. Plantar fasciitis
- D. Muscle atrophy
Correct Answer: C
Rationale: Plantar fasciitis causes foot pain, especially in the morning.
When the nurse talks with a client with multiple sclerosis who has slurred speech, which nursing intervention is contraindicated?
- A. Encouraging the client to speak slowly
- B. Encouraging the client to speak distinctly
- C. Asking the client to repeat indistinguishable words
- D. Asking the client to speak louder when tired
Correct Answer: D
Rationale: Asking the client to speak louder when tired can exacerbate fatigue and frustration, which is counterproductive for someone with MS.