Nokea
The nurse assessed decorticate rigidity in the unconscious client. What is the best description for this posturing?
- A. Flexion of the upper and lower extremities into a fetal-like position
- B. Rigid extension of the upper and lower extremities and plantar flexion
- C. Complete flaccidity of both upper and lower extremities and hyperextension of the neck
- D. Flexion of the upper extremities, and plantar flexion
Correct Answer: A
Rationale: Decorticate rigidity involves flexion of the upper and lower extremities into a fetal-like position. This posturing indicates damage to the corticospinal tracts above the brainstem and is a sign of severe neurological injury. It is often seen in conditions like traumatic brain injury or stroke.
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Which of the following clients are more likely to suffer from a cerebral hematoma?
- A. A client with a family history of hemophilia; no symptoms
- B. A client receiving platelets for a low platelet count
- C. A client with anemia taking iron
- D. A client with atrial fibrillation on Coumadin
Correct Answer: D
Rationale: Clients on anticoagulants are at higher risk for bleeding complications.
A nursing student is teaching a patient and family about epilepsy prior to the patient's discharge. For which statement should you intervene?
- A. You should avoid consumption of all forms of alcohol.
- B. Wear your medical alert bracelet at all times.
- C. Protect your loved one's airway during a seizure.
- D. It's OK to take over-the-counter medications.
Correct Answer: D
Rationale: Over-the-counter medications can interact with antiepileptic drugs, so this advice is incorrect and requires intervention.
What is the most important method of diagnosing functional headaches?
- A. CT scan
- B. Electromyography (EMG)
- C. Cerebral blood flow studies
- D. Thorough history of the headache
Correct Answer: D
Rationale: A thorough history is critical for diagnosing functional headaches
In the context of brain imaging, what does FMRI stand for?
- A. fast moving recovery imaging
- B. first moveable recording indicator
- C. flexible motion resistance indicator
- D. functional magnetic resonance imaging
Correct Answer: D
Rationale: Functional Magnetic Resonance Imaging (fMRI) is a brain imaging technique that measures brain activity by detecting changes in blood flow. When a brain region is active, it consumes more oxygen, and fMRI captures this increased blood flow. This non-invasive method is widely used in neuroscience to study brain function and map neural activity during various tasks. fMRI has revolutionized our understanding of the brain's organization and function.
When performing a neurologic assessment, the nurse should prioritize:
- A. Observing for any sudden changes in mental status or physical function.
- B. Measuring the patient's body temperature.
- C. Checking the patient's blood pressure.
- D. Assessing the patient's respiratory rate.
Correct Answer: A
Rationale: Sudden changes in mental status or physical function are critical in neurologic assessments. Temperature, blood pressure, and respiratory rate are secondary considerations.