Nokea
The nurse is performing a neurological assessment on a client. She asks the client to smile, close both eyes, and frown. Which cranial nerve (CN) is the nurse testing?
- A. CN V
- B. CN VII
- C. CN VIII
- D. CN XI
Correct Answer: B
Rationale: Cranial nerve VII (facial) controls facial movements like smiling, frowning, and closing eyes.
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Which assessment finding would the nurse expect in a client with long-term venous insufficiency with the presence of a venous ulcer?
- A. decreased or absent pedal pulses with cool or cold foot
- B. the presence of stasis ulcers over the medial malleolus
- C. skin atrophy and pallor with elevation of the affected leg
- D. decreased circumference in the affected leg due to venous constriction
Correct Answer: B
Rationale: Venous insufficiency causes stasis ulcers, typically over the medial malleolus, due to venous pooling and tissue breakdown.
The nurse is caring for a client with cerebral palsy. The nurse should provide frequent rest periods because:
- A. Grimacing and writhing movements decrease with relaxation and rest.
- B. Hypoactive deep tendon reflexes become more active with rest.
- C. Stretch reflexes are increased with rest.
- D. Fine motor movements are improved by rest.
Correct Answer: A
Rationale: Rest reduces spasticity and involuntary movements in cerebral palsy.
The nurse calculates the amount of an antibiotic for injection to be given to an infant. The amount of medication to be administered is 1.25 mL. The nurse should:
- A. Divide the amount into two injections and administer in each vastus lateralis muscle
- B. Give the medication in one injection in the dorsogluteal muscle
- C. Divide the amount in two injections and give one in the ventrogluteal muscle and one in the vastus lateralis muscle
- D. Give the medication in one injection in the ventrogluteal muscle
Correct Answer: A
Rationale: For infants, volumes greater than 1 mL should be divided and administered in separate sites, such as each vastus lateralis, to reduce discomfort and ensure absorption.
The client with varicella will most likely have an order for which category of medication?
- A. Antibiotics
- B. Antipyretics
- C. Antivirals
- D. Anticoagulants
Correct Answer: C
Rationale: Varicella (chickenpox) is a viral infection, and antivirals like acyclovir are commonly prescribed to reduce severity and duration.
A student nurse overhears her instructor using the term pink puffer. The student knows this term refers to a client with which condition?
- A. chronic bronchitis
- B. chronic obstructive pulmonary disease (COPD)
- C. emphysema
- D. allergic asthma
Correct Answer: C
Rationale: Pink puffer' describes emphysema patients, who maintain oxygenation (pink) but hyperventilate (puffer) due to alveolar destruction.