Nokea
The nurse assesses the motor functions during a neurologic examination of a client. Which of the ff steps will help the nurse perform the examination effectively? Choose all that apply
- A. Allow the client to grasp the nurses hand firmly
- B. Check the patient's sensitivity to heat, cold, touch, and pain.
- C. Ask the client to pick up small and large objects between the thumb and forefinger
- D. Ask questions that require cognition and logic
Correct Answer: A
Rationale: A. Allowing the client to grasp the nurse's hand firmly is essential to assess grip strength, coordination, and muscle tone, which are important aspects of motor function evaluation during a neurologic examination.
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Which of the following BP changes alerts the nurse to increasing ICP, and should be reported immediately?
- A. Gradual increase
- B. Widening pulse pressure
- C. Rapid drop followed by gradual increase
- D. Rapid fluctuations
Correct Answer: B
Rationale: Widening pulse pressure is indicative of increasing intracranial pressure (ICP) and must be reported immediately. Pulse pressure is calculated by subtracting the diastolic blood pressure from the systolic blood pressure. An increasing pulse pressure can suggest a rise in ICP due to factors like cerebral edema or hemorrhage. This change indicates increased pressure exerted on blood vessels within the brain, potentially leading to serious consequences like brain herniation. Thus, recognizing and promptly reporting a widening pulse pressure is crucial to prevent further complications and enable appropriate interventions for the patient.
Which of the following statements would be the nurse's response to a famiiy member asking questions about a client's transient ischemic attack (TIA)?
- A. "I think you should ask the doctor. Would you like me to cail him for you?"
- B. " The blood supply to the brain has decreased causing permanent brain damage."
- C. "It Is a temporary interruption in the blood flow to the brain."
- D. "TIA means a transient ischemic attack."
Correct Answer: C
Rationale: The correct response would be: "It is a temporary interruption in the blood flow to the brain." This response provides a clear and accurate explanation of a transient ischemic attack (TIA), which is commonly known as a "mini-stroke." A TIA is indeed a temporary episode where there is a brief interruption in the blood flow to the brain, leading to symptoms similar to those of a stroke, but without lasting damage. This response would give the family member a better understanding of what a TIA is and help alleviate concerns about permanent brain damage.
A 2-year-old child presents with a peeling, erythematous rash on the hands and feet. The mother reports that he has become ill tempered and refuses to walk about, preferring to lie in bed. Physical examination reveals an irritable, pale child with photophobia. Temperature is 98.5°F, heart rate is 80/minute, and respiratory rate is 23/minute. Tremor of the tongue is evident. Further history and follow-up evaluation reveal that the child's elder brothers have been playing with liquid mercury. Which is the most likely diagnosis?
- A. Measles
- B. Fifth disease
- C. Kawasaki disease
- D. Acrodynia
Correct Answer: D
Rationale: Acrodynia, also known as pink disease, is caused by chronic mercury exposure. The symptoms described, including the rash, irritability, photophobia, and tremor, are consistent with mercury poisoning.
Childhood primary brain stem tumors are a heterogeneous group of tumors; the outcome usually depends on the tumor location. Which tumor, depending on the site of tumor, carries the worst prognosis?
- A. focal dorsally exophytic
- B. cervicomedullary diffuse intrinsic
- C. none of the above
- D. diffuse intrinsic
Correct Answer: D
Rationale: Diffuse intrinsic pontine gliomas (DIPG) have the worst prognosis among brainstem tumors.
Which of the following is the most common cause of hyperaldosteronism?
- A. Excessive sodium intake
- B. Deficient potassium intake
- C. A pituitary adenoma
- D. An adrenal adenoma
Correct Answer: D
Rationale: The most common cause of hyperaldosteronism is an adrenal adenoma, which is a benign tumor of the adrenal gland. Adrenal adenomas produce excessive amounts of aldosterone, a hormone that regulates sodium and potassium balance in the body. This overproduction of aldosterone can lead to increased sodium retention and potassium excretion, resulting in hypertension and low potassium levels in the blood. Excessive sodium intake and deficient potassium intake are not common causes of hyperaldosteronism. Pituitary adenomas are associated with conditions such as Cushing's syndrome or acromegaly, but not hyperaldosteronism.