Nokea
The nurse is assessing a patient's pupils for reactivity to light. Which cranial nerve (CN) is being tested?
- A. CN III
- B. CN IV
- C. CN VI
- D. CN XII
Correct Answer: A
Rationale: Cranial nerve III (oculomotor) controls pupil constriction and is tested when assessing pupillary reactivity to light. Cranial nerves IV, VI, and XII control eye movement and tongue movement but are not directly involved in pupillary reflexes. Testing CN III is essential for evaluating brainstem function.
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To elicit a Plantar reflex:
- A. Gently tap the Achilles tendon
- B. Stroke the lateral aspect of the sole of the foot from heel to ball
- C. Present a noxious odor to a person
- D. Observe the person walking heel to toe
Correct Answer: B
Rationale: The Plantar reflex is elicited by stroking the lateral aspect of the sole of the foot from the heel to the ball of the foot with a blunt object. This tests the integrity of the corticospinal tract. A normal response in adults is plantar flexion of the toes.
If a nurse observes a sudden change in a client's vital signs, what immediate step should the nurse take?
- A. Inform the physician
- B. Change the environmental settings of the client
- C. Alter the diet intake of the client
- D. Decrease the physical activity of the client
Correct Answer: A
Rationale: Immediate medical attention is necessary for significant changes in vital signs.
Which of the following nursing diagnoses pertains to a client with a neurological deficit in relation to his marriage?
- A. Risk for Disuse Syndrome related to musculoskeletal inactivity and neuromuscular impairment
- B. Total Urinary Incontinence or Urinary Retention related to effects of disease or injury to the nervous system or spinal cord nerves
- C. loss of bladder tone
- D. Impaired Physical Mobility related to muscle weakness and paralysis
Correct Answer: D
Rationale: Neurological deficits can affect sexual function, impacting relationships.
For a patient with unilateral neglect related to sensory-perceptual deficits, what nursing intervention is important during rehabilitation?
- A. Avoid positioning the patient on the affected side.
- B. Place all objects for care on the patient's unaffected side.
- C. Teach the patient to care consciously for the affected side.
- D. Protect the affected side from injury with pillows and supports.
Correct Answer: C
Rationale: Teaching conscious care helps the patient acknowledge and attend to their affected side
A patient arrived in the ER with a head injury. She is unconscious. The physician and a fellow nurse are the only staff members near the patient. Her husband begins to criticize the attending physician and suggest that a different physician should care for this patient. What is the best response?
- A. Report the nurse to the attending physician.
- B. Call the nurse away from the patient and remind him that the patient can still hear even if unconscious.
- C. Ask the nurse why he has such feelings.
- D. Simply nod your head in agreement.
Correct Answer: B
Rationale: Unconscious patients can still perceive their surroundings; thus, maintaining professional communication is important.