Nokea
The nurse is caring for a boy who has muscular dystrophy. When planning assistance with the patients ADLs, what goal should the nurse prioritize?
- A. Promoting the patients recovery from the disease
- B. Maximizing the patients level of function
- C. Ensuring the patients adherence to treatment
- D. Fostering the familys participation in care
Correct Answer: B
Rationale: Muscular dystrophy is incurable, so maximizing function through ADLs is the priority. Family participation and adherence support this goal but are secondary.
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The nurse educator is discussing neoplasms with a group of recent graduates. The educator explains that the effects of neoplasms are caused by the compression and infiltration of normal tissue. The physiologic changes that result can cause what pathophysiologic events? Select all that apply.
- A. Intracranial hemorrhage
- B. Infection of cerebrospinal fluid
- C. Increased ICP
- D. Focal neurologic signs
- E. Altered pituitary function
Correct Answer: C,D,E
Rationale: Neoplasms cause increased ICP, focal neurologic signs, and altered pituitary function through compression. Hemorrhage and CSF infection are not typical effects.
A male patient with a metastatic brain tumor is having a generalized seizure and begins vomiting. What should the nurse do first?
- A. Perform oral suctioning.
- B. Page the physician.
- C. Insert a tongue depressor into the patients mouth.
- D. Turn the patient on his side.
Correct Answer: D
Rationale: Turning the patient on their side prevents aspiration of vomit during a seizure. Tongue depressors are contraindicated, and suctioning or paging the physician are secondary actions.
An older adult has encouraged her husband to visit their primary care provider, stating that she is concerned that he may have Parkinsons disease. Which of the wifes descriptions of her husbands health and function is most suggestive of Parkinsons disease?
- A. Lately he seems to move far more slowly than he ever has in the past.
- B. He often complains that his joints are terribly stiff when he wakes up in the morning.
- C. Hes forgotten the names of some people that weve known for years.
- D. Hes losing weight even though he has a ravenous appetite.
Correct Answer: A
Rationale: Bradykinesia is a hallmark of Parkinson's disease. Joint stiffness, memory loss, or weight loss with increased appetite are not typical symptoms.
The nurse is caring for a patient newly diagnosed with a primary brain tumor. The patient asks the nurse where his tumor came from. What would be the nurses best response?
- A. Your tumor originated from somewhere outside the CNS.
- B. Your tumor likely started out in one of your glands.
- C. Your tumor originated from cells within your brain itself.
- D. Your tumor is from nerve tissue somewhere in your body.
Correct Answer: C
Rationale: Primary brain tumors arise from brain cells, unlike secondary tumors from outside the CNS. Glandular or nerve tissue origins are less specific.
The nurse is caring for a patient who is scheduled for a cervical discectomy the following day. During health education, the patient should be made aware of what potential complications?
- A. Vertebral fracture
- B. Hematoma at the surgical site
- C. Scoliosis
- D. Renal trauma
Correct Answer: B
Rationale: Hematoma at the surgical site is a key complication of cervical diskectomy, risking cord compression. Fractures, scoliosis, or renal trauma are not typical risks.