Nokea
The male client diagnosed with multiple sclerosis states he has been investigating alternative therapies to treat his disease. Which intervention is most appropriate by the nurse?
- A. Encourage the therapy if it is not contraindicated by the medical regimen.
- B. Tell the client only the health-care provider should discuss this with him.
- C. Ask how his significant other feels about this deviation from the medical regimen.
- D. Suggest the client research an investigational therapy instead.
Correct Answer: A
Rationale: Encouraging alternative therapies that are safe and not contraindicated can empower the client and support their autonomy in managing their condition.
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The nurse will document which reflex is present when there is dorsiflexion of the great toe with fanning of other toes?
- A. Brudzinski
- B. Babinski (damage to the corticospinal tracts)
- C. Trousseaus
- D. Kernigs
Correct Answer: B
Rationale: The Babinski reflex, characterized by dorsiflexion of the great toe and fanning of the other toes, is abnormal in adults and indicates damage to the corticospinal tract. This reflex is normal in infants but disappears as the nervous system matures. Its presence in adults suggests neurological pathology.
Which of these physiological changes would not be considered part of the sympathetic fight-or-flight response?
- A. increased heart rate
- B. increased sweating
- C. dilated pupils
- D. increased stomach motility
Correct Answer: D
Rationale: The correct answer is D: increased stomach motility. In the sympathetic fight-or-flight response, the body prioritizes blood flow to essential organs and muscles, leading to decreased activity in non-essential functions like digestion (stomach motility). This is to conserve energy for immediate action. Increased heart rate, sweating, and dilated pupils are all part of the fight-or-flight response as they prepare the body for quick action and heightened awareness.
A 78-year-old woman has a physiologic change related to aging in her joints. What is an appropriate nursing intervention related to common changes of aging in the musculoskeletal system?
- A. Encourage rest to eliminate fatigue
- B. Provide all care for the patient to ensure that care is completed
- C. Encourage eating enough calories to avoid the risk for impaired skin integrity
- D. Have the patient exercise to maintain muscle strength and avoid the risk for falls
Correct Answer: D
Rationale: Exercise helps maintain strength and balance.
After talking with the health care provider, the patient asks what the blood-brain barrier does. What is the best description that the nurse can give the patient?
- A. Protects the brain from external trauma
- B. Protects against harmful blood-borne agents
- C. Provides for flexibility while protecting the spinal cord
- D. Forms the outer layer of protective membranes around the brain and spinal cord
Correct Answer: B
Rationale: The blood-brain barrier protects the brain against harmful substances in the blood.
To assess a patient's ability to follow commands, the nurse should:
- A. Ask the patient to perform simple tasks, such as closing their eyes or squeezing their hand.
- B. Measure the patient's body temperature.
- C. Inspect the patient's skin for abnormalities.
- D. Check the patient's respiratory rate.
Correct Answer: A
Rationale: Following commands is assessed by asking the patient to perform simple tasks. Body temperature, skin inspection, and respiratory rate are unrelated to this assessment.