Nokea
The nurse is preparing to discharge a patient with chronic low back pain. Which statement by the patient indicates that additional teaching is necessary?
- A. I will avoid exercise because the pain gets worse.
- B. I will use heat or ice to help control the pain.
- C. I will not wear high-heeled shoes at home or work.
- D. I will purchase a firm mattress to replace my old one.
Correct Answer: A
Rationale: Avoiding exercise can lead to muscle weakness and worsening of back pain; exercise is often recommended as part of the treatment plan.
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Which of the following animals is NOT a typical reservoir for the spread of rabies?
- A. dog
- B. bat
- C. skunk
- D. chicken
Correct Answer: D
Rationale: The correct answer is D: chicken. Chickens are not typical reservoirs for rabies as they are not known to carry the rabies virus. Dogs, bats, and skunks can serve as reservoirs for rabies due to their susceptibility to the virus. Dogs are a common source of rabies transmission to humans, while bats and skunks are known carriers of the virus. Therefore, the correct answer is D as chickens do not play a role in the spread of rabies.
A medical-surgical nurse works with a patient diagnosed with a somatic system disorder. Care planning is facilitated by understanding that the patient will probably:
- A. readily seek psychiatric counseling.
- B. be resistant to accepting psychiatric help.
- C. attend psychotherapy sessions without encouragement.
- D. be eager to discover the true reasons for physical symptoms.
Correct Answer: B
Rationale: The correct answer is B because individuals with somatic symptom disorders often resist psychiatric help due to their strong belief that their physical symptoms have a medical, not psychological, cause. This resistance can stem from fear of being labeled as "crazy" or of not being taken seriously. Therefore, the nurse should be aware of this resistance and approach the patient with empathy and understanding.
A: This is incorrect because individuals with somatic symptom disorders often do not readily seek psychiatric counseling due to their belief that their symptoms are purely physical.
C: This is incorrect because individuals with somatic symptom disorders may not attend psychotherapy sessions without encouragement due to their resistance to psychiatric help.
D: This is incorrect because individuals with somatic symptom disorders may not be eager to discover the true reasons for physical symptoms as they strongly believe in the medical cause.
The nurse suspects that a patient will be diagnosed as being in a comatose state based upon the Glasgow Coma Scale score. What score does the patient need to have to be identified as comatose?
- A. 7
- B. 9
- C. 11
- D. 13
Correct Answer: A
Rationale: A GCS score of 7 or less indicates a comatose state, while a score of 15 indicates full alertness. Scores of 9, 11, and 13 suggest varying degrees of neurological impairment but not coma. Recognizing a comatose state is critical for patient management.
A patient with a fractured right hip has an anterior open reduction and internal fixation of the fracture. What should the nurse plan to do postoperatively?
- A. Get the patient up to the chair on the first postoperative day.
- B. Position the patient only on the back and the unoperative side.
- C. Keep the leg abductor pillow on the patient even when bathing.
- D. Ambulate the patient with partial weight bearing by discharge.
Correct Answer: C
Rationale: Using an abductor pillow maintains proper alignment.
Fibrillations (fasciculations) may develop with disease in:
- A. lateral column of the spinal cord
- B. posterior horn of the spinal cord
- C. anterior horn of the spinal cord
- D. internal capsule
Correct Answer: C
Rationale: Anterior horn of the spinal cord is the correct answer because fibrillations and fasciculations are spontaneous muscle contractions that occur due to the degeneration of lower motor neurons located in the anterior horn. These contractions are a sign of denervation and are commonly seen in conditions like amyotrophic lateral sclerosis (ALS).