Nokea
The nurse is caring for an individual with a head injury and notes unequal pupils. Which term should the nurse use to document this finding?
- A. Aphasia
- B. Nystagmus
- C. Anisocoria
- D. Ophthalmoplegia
Correct Answer: C
Rationale: Anisocoria refers to unequal pupil size, which can indicate neurological dysfunction. Aphasia is a language disorder, nystagmus is involuntary eye movement, and ophthalmoplegia is the inability to move the eyes. Documenting anisocoria accurately is important for assessing potential brain injury.
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Which nerve projects to the hypothalamus to indicate the level of light stimuli in the retina?
- A. glossopharyngeal
- B. oculomotor
- C. optic
- D. vagus
Correct Answer: C
Rationale: The correct answer is C: optic nerve. The optic nerve carries visual information from the retina to the brain, including the hypothalamus. Light stimuli levels are detected by the retina and transmitted via the optic nerve to the hypothalamus for regulating various physiological processes.
A: glossopharyngeal - This nerve is responsible for taste and some motor functions in the throat, not related to light stimuli detection in the retina.
B: oculomotor - This nerve controls eye movements, not directly involved in transmitting light stimuli levels to the hypothalamus.
D: vagus - This nerve is responsible for parasympathetic functions in the body, not related to processing light stimuli information in the retina.
An elderly client has undergone electromyography tests to evaluate muscle weakness and deterioration. The client complains of slight pain after the tests. Which of the following nursing interventions would help relieve the client's discomfort?
- A. Administering topical analgesics to the area where the needle electrodes were inserted
- B. Massaging the area where the needle electrodes were inserted
- C. Applying a cold pack to the area where the needle electrodes were inserted
- D. Applying warm compresses to the area where the needle electrodes were inserted
Correct Answer: C
Rationale: Cold packs can help reduce inflammation and numb the area, relieving discomfort.
A patient arrives in the ER with blurred and double vision, muscle weakness, and intolerance of temperature changes. The physician suspects multiple sclerosis. What test would you expect the physician to do in order to confirm his or her suspicions?
- A. CBC with a very low WBC count.
- B. MRI with gadolinium showing demyelination of nerve fibers.
- C. Endocrine function study with a low growth hormone and high T3 and T4.
- D. Fasting glucose test with a result over 300 mg/dL.
Correct Answer: B
Rationale: MRI with gadolinium is used to identify demyelination, which is characteristic of multiple sclerosis.
With regard to nystagmus:
- A. caloric nystagmus occurs when iced water is poured into the ear
- B. vestibular nystagmus occurs as a consequence of head rotation
- C. optokinetic nystagmus occurs as a consequence of the relative motion of the visual field
- D. all above
Correct Answer: D
Rationale: Caloric, vestibular, and optokinetic nystagmus are all types of nystagmus caused by specific stimuli, such as temperature changes, head rotation, or visual field motion.
The patient who has right homonymous hemianopia and right hemiparesthesia would indicate his awareness of his safety self-promotion by
- A. keeping frequently used objects on his left side
- B. asking his visitors to approach him from his affected side
- C. frequently checking the position of the affected extremities in space
- D. adhering to one-handed activities
Correct Answer: A
Rationale: Placing objects on the unaffected side ensures visibility.