The nurse is assessing the client’s sensory system. Which assessment data indicate an abnormal stereognosis test?
- A. The client is unable to identify which way the toe is being moved.
- B. The client cannot discriminate between sharp and dull objects.
- C. The toes contract and draw together when the sole of the foot is stroked.
- D. The client is unable to identify a key in the hand with both eyes closed.
Correct Answer: D
Rationale: Abnormal stereognosis is the inability to identify objects (e.g., a key) by touch with eyes closed, indicating parietal lobe dysfunction. Toe movement, sharp/dull, and Babinski reflex test other functions.
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What should the nurse include when teaching the client with Parkinson's disease?
- A. He should try to continue working as long as he can remain sitting most of the day.
- B. Drooling may be reduced somewhat if he remembers to swallow frequently.
- C. He should return monthly for lab tests, which will predict the progression of the disease.
- D. Emotional stress has no effect on voluntary muscle control in clients with Parkinson's disease.
Correct Answer: B
Rationale: Frequent swallowing can reduce drooling, a common symptom in Parkinson's disease, improving comfort and social interaction.
How should a nurse walk a client who is blind?
- A. Stand slightly behind the client and tell her when to turn
- B. Stand slightly behind and to the side of the client and guide her by holding her hand
- C. Walk slightly ahead with the client's arm inside the nurse's arm
- D. Walk beside the client and gently guide her by grasping her elbow
Correct Answer: C
Rationale: Walking slightly ahead with the client's arm inside the nurse's arm provides guidance and safety for a blind client.
The client comes to the emergency department after splashing chemicals into the eyes. Which intervention should the nurse implement first?
- A. Have the client move the eyes in all directions.
- B. Administer a broad-spectrum antibiotic.
- C. Irrigate the eyes with normal saline solution.
- D. Determine when the client had a tetanus shot.
Correct Answer: C
Rationale: Immediate irrigation with normal saline removes chemicals, preventing corneal damage. Eye movement, antibiotics, and tetanus history are secondary.
A cataract extraction is performed on a client's right eye. What is the priority nursing care immediately postoperative?
- A. Assist her to turn, cough, and deep breathe every two hours.
- B. Keep her NPO for four hours.
- C. Assist her in moving her arms and legs in ROM.
- D. Position client on her right side.
Correct Answer: C
Rationale: Assisting with range of motion prevents complications like stiffness while avoiding strain on the surgical eye.
The doctor orders a Tensilon test for a woman suspected of having myasthenia gravis. Which statement is true about this test?
- A. A positive result will be evident within one minute of injection of Tensilon if she has myasthenia gravis.
- B. This is of diagnostic value in only 25% of patients with myasthenia gravis.
- C. Administration of Tensilon causes an immediate decrease in muscle strength for about an hour in persons with myasthenia gravis.
- D. Tensilon works by blocking the action of acetylcholine at the myoneural junction.
Correct Answer: A
Rationale: A positive Tensilon test shows increased muscle strength within one minute, confirming myasthenia gravis, as Tensilon enhances acetylcholine activity.