Nokea
The nurse enters the room of a client diagnosed with acute exacerbation of multiple sclerosis and finds the client crying. Which statement is the most therapeutic response for the nurse to make?
- A. Why are you crying? The medication will help the disease.
- B. You seem upset. I will sit down and we can talk for awhile.
- C. Multiple sclerosis is a disease that has good times and bad times.
- D. I will have the chaplain come and stay with you for a while.
Correct Answer: B
Rationale: Acknowledging the client's emotions and offering support is the most therapeutic response, as it validates their feelings and provides comfort.
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Which is the largest branch of the internal carotid artery?
- A. ophthalmic artery
- B. anterior cerebral artery
- C. middle cerebral artery
- D. striate artery
Correct Answer: C
Rationale: The middle cerebral artery is the largest branch of the internal carotid artery and supplies a significant portion of the cerebral cortex, including areas responsible for motor and sensory functions.
A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient's deep tendon reflexes?
- A. Reflexes will be normal.
- B. Reflexes cannot be elicited.
- C. All reflexes will be diminished but present.
- D. Some reflexes will be present, depending on the area of injury.
Correct Answer: A
Rationale: The correct answer is A: Reflexes will be normal. In a patient with a head injury resulting from trauma and no other injuries, deep tendon reflexes are typically unaffected by the injury. The brain stem controls deep tendon reflexes, and since there are no other injuries, the reflexes should remain normal. Choices B, C, and D are incorrect because they do not align with the typical response of deep tendon reflexes in a head injury without other injuries. Choice B stating that reflexes cannot be elicited is incorrect as deep tendon reflexes are usually intact in this scenario. Choice C suggesting all reflexes will be diminished but present is incorrect as deep tendon reflexes are typically not affected by head injuries. Choice D stating that some reflexes will be present depending on the area of injury is incorrect because deep tendon reflexes are primarily controlled by the brain stem, which is not directly affected in this situation.
In the acute phase following a cerebrovascular accident, patients have a tendency to develop pressure lesions for all of the following reasons EXCEPT
- A. high degree of muscle spasticity
- B. accompanying sensory loss
- C. interference with altered autonomic reflexes
- D. diminished muscle use
Correct Answer: A
Rationale: Spasticity does not typically contribute to pressure ulcers.
In humans, transmission of nerve impulses across a synaptic cleft is carried out by ________.
- A. sodium ions
- B. potassium ions
- C. neurotransmitter molecules
- D. the nodes of Ranvier
Correct Answer: C
Rationale: Transmission of nerve impulses across a synaptic cleft is mediated by neurotransmitter molecules. When an action potential reaches the axon terminal, it triggers the release of neurotransmitters into the synaptic cleft. These chemicals bind to receptors on the postsynaptic neuron, initiating a new electrical signal. Neurotransmitters are essential for communication between neurons and play a key role in neural signaling.
An appropriate nursing intervention for this patient?
- A. Post clocks and calendars in the patient's environment.
- B. Establish and consistently follow a daily schedule with the patient.
- C. Monitor the patient's activities to maintain a safe patient environment.
- D. Stimulate thought processes by asking the patient questions about recent activities.
Correct Answer: B
Rationale: Consistent schedules help orient patients with dementia