Nokea
The nurse is caring for a patient diagnosed with a cerebral tumor. For which function should the nurse expect to assess an abnormality?
- A. Reflex movement
- B. Movement and speech
- C. Coordination and posture
- D. Heart rate and respiratory rate
Correct Answer: B
Rationale: A cerebral tumor in the frontal lobe may affect movement and speech, as this area contains the motor cortex and Broca's area. Reflex movements are controlled by the spinal cord, coordination by the cerebellum, and heart rate by the medulla. Assessing movement and speech is critical for localizing the tumor's effects.
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Hyperventilation causes:
- A. an alkaline urine
- B. a fall in the plasma bicarbonate concentration
- C. increased cardiac output
- D. all above
Correct Answer: D
Rationale: Hyperventilation causes respiratory alkalosis, leading to alkaline urine, reduced plasma bicarbonate, and increased cardiac output due to decreased CO2 levels.
You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to the LPN/LVN?
- A. Complete admission assessment.
- B. Set up oxygen and suction equipment.
- C. Place a padded tongue blade at bedside.
- D. Pad the side rails before patient arrives.
Correct Answer: D
Rationale: Padding the side rails is a safety measure that can be done by an LPN/LVN without requiring complex assessment skills.
An elderly patient presents with a right-sided headache and acute loss of vision on the same side. Tenderness is noted to the right temporal region as well as to the scalp. To obtain a definitive diagnosis, the nurse practitioner will order:
- A. Erythrocyte sedimentation rate (ESR)
- B. C-reactive protein (CRP)
- C. Temporal artery biopsy
- D. CT scan of the head
Correct Answer: C
Rationale: The correct answer is C: Temporal artery biopsy. This is the gold standard for diagnosing giant cell arteritis, which presents with symptoms such as headache, vision loss, and tenderness to the temporal region and scalp. The biopsy will show characteristic inflammatory changes in the artery wall.
A: ESR and B: CRP are nonspecific markers of inflammation and can be elevated in various conditions, including giant cell arteritis, but they do not provide a definitive diagnosis.
D: CT scan of the head may show signs of inflammation in the temporal artery, but it is less sensitive than a biopsy for diagnosing giant cell arteritis.
Which of the following nursing interventions is taken as a precautionary measure if shock develops when a client with spinal cord injury is hospitalized?
- A. An IV line is inserted to provide access to a vein.
- B. Head and back are immobilized mechanically with a cervical collar and back support.
- C. Traction with weights and pulleys is applied.
- D. A turning frame is used.
Correct Answer: A
Rationale: IV access is critical for administering fluids and medications in shock.
A client with multiple sclerosis is observed transferring from the bed to a motorized wheelchair and applying splints to the lower extremities before entering the bathroom to perform morning self-care. What could the nurse conclude regarding this observation?
- A. The client uses assistive devices to optimize autonomy.
- B. The client needs instruction to conduct morning care before applying splints to lower extremities.
- C. The client is dependent upon assistive devices.
- D. The client is reliant upon assistive devices for independent.
Correct Answer: A
Rationale: The client's use of assistive devices demonstrates their ability to maintain independence and adapt to their physical limitations.