Nokea
The nurse is assisting as a neurosurgeon examines a patient who has a positive Babinski reflex. What assessment finding should the nurse expect to observe?
- A. The leg flexes when the patellar tendon is struck.
- B. The leg extends when the patellar tendon is struck.
- C. The big toe extends when the sole of the foot is stroked.
- D. Toes curl downward when the sole of the foot is stroked.
Correct Answer: C
Rationale: A positive Babinski reflex, indicative of neurological dysfunction, involves extension of the big toe and fanning of the other toes when the sole of the foot is stroked. Flexion or extension of the leg is associated with other reflexes. Recognizing a positive Babinski reflex is important for assessing upper motor neuron lesions.
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Which of the following positions would be most comfortable for Mr. Tucker?
- A. Supine with head elevated 20-30° and knees flexed
- B. Prone with head turned to side and feet extending over mattress edge
- C. Flat on back with the bed gatched in the middle
- D. Supine with a hard thick pillow under the lumbar region
Correct Answer: A
Rationale: This position reduces strain on the back muscles.
Regarding the blood supply of the cerebral cortex
- A. Middle cerebral is contralateral arm, leg and speech areas
- B. Anterior cerebral is contralateral leg, micturition and defaecation
- C. Middle cerebral is ipsilateral arm, face and vision
- D. Posterior cerebral is ipsilateral vision
Correct Answer: B
Rationale: The anterior cerebral artery supplies the medial surface of the brain, including areas responsible for motor and sensory functions of the contralateral leg. It also influences micturition and defecation.
What sign/symptom would NOT be associated with infant botulism?
- A. difficulty suckling
- B. limp body
- C. stiff neck
- D. weak cry
Correct Answer: C
Rationale: The correct answer is C: stiff neck. Infant botulism is characterized by muscle weakness, including difficulty suckling, a limp body, and a weak cry. A stiff neck is not typically associated with infant botulism. The toxin affects the nervous system, causing muscle paralysis, but does not typically lead to neck stiffness. Therefore, choice C is the correct answer. Choices A, B, and D are incorrect because they are all common signs and symptoms of infant botulism, reflecting the muscle weakness and paralysis caused by the toxin.
A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care?
- A. No precautions are required as long as antibiotics have been started
- B. Maintain enteric precautions
- C. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics
- D. Maintain neutropenic precautions
Correct Answer: C
Rationale: Respiratory isolation precautions are necessary for at least 24 hours after starting antibiotics to prevent the spread of bacterial meningitis, which is transmitted through respiratory droplets. This precaution protects healthcare workers and other patients from exposure to the infectious agent.
You are caring for a patient with a recurrent glioblastoma who is receiving dexamethasone (Decadron) 4 mg IV every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information concerns you the most?
- A. The patient does not recognize family members.
- B. The blood glucose level is 234 mg/dL.
- C. The patient complains of a continued headache.
- D. The daily weight has increased 1 kg.
Correct Answer: A
Rationale: Changes in recognition could indicate neurological deterioration requiring immediate attention.