Nokea
The nurse explains that the two divisions of the autonomic nervous system work to maintain homeostasis. Which action is the first autonomic event following a stressful or frightening event?
- A. Parasympathetic nervous system dominates
- B. Blood pressure, heart rate, and adrenaline output decrease
- C. Sympathetic nervous system dominates
- D. Heart rate and blood pressure rise, secretion of adrenaline
Correct Answer: D
Rationale: In the event of a frightening event, the sympathetic nervous system dominates and increases the blood pressure, heart rate, and adrenaline output in the 'fight or flight' mechanism. The body is calmed by the parasympathetic nervous system dominating and reducing the heart rate, blood pressure, and adrenaline output.
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The nurse assures an anxious family member of a 92-year-old patient who is demonstrating signs of dementia that many causes of dementia are reversible and preventable. Which disorder is one example?
- A. Hypotension
- B. Alzheimer's disease
- C. Diabetes
- D. Parkinson disease
Correct Answer: A
Rationale: Some forms of dementia are reversible. Dementia caused by hypotension, anemia, drug toxicity, metabolic disturbance, and malnutrition can all be corrected to abolish the dementia.
Which sign is the first sign of Bell's palsy?
- A. Inability to wrinkle forehead and pucker lips on affected side
- B. Sudden pain in nostril on affected side
- C. Excessive salivation on the affected side
- D. Excessive mucus running from nostril on affected side
Correct Answer: A
Rationale: Unilateral weakness of the facial muscles usually occurs, resulting in a flaccidity of the affected side of the face with inability to wrinkle the forehead, close the eyelid, pucker the lips, smile, frown, whistle, or retract the mouth on that side. The face appears asymmetric.
In which way will the nurse instruct a patient with Parkinson disease to improve activity level?
- A. To use a soft mattress to relax the spine.
- B. To walk with a shuffling gait to avoid tripping.
- C. To walk with hands folded behind back to help balance.
- D. To sit in hard chair with arms for posture control.
Correct Answer: C
Rationale: The patient with Parkinson disease can improve the activity level holding the hands folded behind to keep better balance and keep the arms from hanging stiffly at the side. The patient should be sleeping on a firm mattress without a pillow to prevent spinal curvature, Walk with a lifting of the feet to avoid tripping and 'freezing.'
Which food should the person who experiences migraine headaches avoid?
- A. Yogurt
- B. Caffeine
- C. Beef
- D. Pears
- E. Marinated foods
- F. Milk
Correct Answer: A,B,E
Rationale: Some foods may cause or worsen headaches. Foods that may provoke headaches include vinegar, chocolate, yogurt, alcohol, fermented or marinated foods, ripened cheese, cured sandwich meat, caffeine, and pork.
The nurse is aware that when assessing a patient by the FOUR score coma scale, the patient is assessed in four categories: eye response, brainstem reflexes, motor response, and respiration. In which manner are these results reported?
- A. As a sum of the scores of the four categories
- B. As part of the Glasgow Coma Scale
- C. As individual scores in each category
- D. As progressive scores during a 24-hour period
Correct Answer: C
Rationale: The FOUR score coma scale assesses the patient in four categories: eye response, brainstem reflexes, motor response, and respiration. The scores are reported as individual scores in each category. It is frequently done in conjunction with or as an alternative to the Glasgow Coma Scale, not part of it.