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The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits:
- A. A positive Brudzinski's sign
- B. A negative Kernig's sign
- C. Absence of nuchal rigidity
- D. A Glascow Coma Scale score of 15
Correct Answer: A
Rationale: A positive Brudzinski's sign, where flexion of the neck causes involuntary flexion of the hips and knees, is a classic sign of meningitis. Meningitis is a potential complication after craniotomy due to the breach in the protective meninges, allowing pathogens to enter the central nervous system. Other signs include fever, headache, and nuchal rigidity.
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What hormone is important in milk production and maintaining lactation?
- A. Estrogen
- B. Oxytocin
- C. Prolactin
- D. Adrenaline
Correct Answer: C
Rationale: Prolactin is the correct answer because it is the hormone produced by the pituitary gland that stimulates milk production in the mammary glands. During lactation, prolactin levels remain elevated to ensure a continuous supply of milk. While oxytocin is involved in milk ejection, prolactin is primarily responsible for milk synthesis and maintenance of lactation.
While collecting data the nurse learns that a patient with a neurological illness has not had a sense of smell for several decades. Which part of the central nervous system should the nurse question as being damaged in this patient?
- A. Brainstem
- B. Occipital lobe
- C. Hypothalamus
- D. Temporal lobe
Correct Answer: D
Rationale: The olfactory nerve (cranial nerve I) originates in the temporal lobe, and damage to this area can result in anosmia (loss of smell). The brainstem, occipital lobe, and hypothalamus are not directly involved in the sense of smell. Assessing olfactory function can provide clues about neurological damage.
Dilatation of the peripheral arterial blood vessels can be caused by:
- A. thromboxane A2
- B. adenosine diphosphate
- C. endothelin
- D. prostaglandins
Correct Answer: D
Rationale: Prostaglandins, particularly prostacyclin (PGI2), are potent vasodilators. Thromboxane A2, adenosine diphosphate, and endothelin are vasoconstrictors and do not cause peripheral arterial dilatation.
Mr. K., aged 60 years, has a diagnosis of transient ischemic attack. An essential aspect of his history that needs to be documented is
- A. sudden, brief loss of sensory, motor, or visual function
- B. determining if he has any allergies
- C. any history of neurologic disease
- D. his medication history, both prescribed and over-the-counter
Correct Answer: A
Rationale: Sudden neurological deficits are hallmark symptoms of TIA.
A patient recovering from an acute exacerbation of RA tells the nurse that she is too tired to bathe. What should the nurse do for this patient?
- A. Give the patient a bed bath to conserve her energy.
- B. Allow the patient a rest period before showering with the nurse's help.
- C. Tell the patient that she can skip bathing if she will walk in the hall later.
- D. Inform the patient that it is important for her to maintain self-care activities.
Correct Answer: A
Rationale: Conserving energy is critical during flares.