Nokea
The nurse is providing care for a client admitted to the hospital after a motor vehicle accident. After being informed by family members that the patient is deaf and mute, which action should the nurse take?
- A. Avoid use of the Glasgow Coma Scale.
- B. Consider the Babinski response invalid.
- C. Utilize a three-point scale to grade muscle strength.
- D. Perform the Romberg test with the patient in a seated position.
Correct Answer: A
Rationale: The Glasgow Coma Scale (GCS) cannot be fully assessed in a patient who is deaf and mute, as verbal responses cannot be evaluated. The Babinski reflex, muscle strength grading, and Romberg test are not affected by the patient's communication abilities. Alternative assessment tools should be used.
You may also like to solve these questions
An older adult woman is admitted to the emergency department after falling at home. The nurse cautions her not to put weight on the leg after finding what in the patient assessment?
- A. Inability to move the toes and ankle
- B. Edema of the thigh extending to the knee
- C. Internal rotation of the leg with groin pain
- D. Shortening and external rotation of the leg
Correct Answer: D
Rationale: Shortening and external rotation indicate a hip fracture.
During the rehabilitative phase following his cerebrovascular accident Mr. K. is taught measures to relieve or prevent constipation. Which of these statements indicates that Mr. K. needs further health teaching?
- A. I eat whole-wheat bread with my meals.
- B. I eat fruit three times a day.
- C. I don't drink fluids after 4 P.M.
- D. I don't like to take enemas.
Correct Answer: C
Rationale: Restricted fluid intake contributes to constipation.
In Drosophila, the neuroectoderm is located ventrally during gastrulation, while in mice or frogs, the neuroectoderm is located dorsally. Which statement best describes how the two systems are similar or different?
- A. There are no similarities between flies and vertebrates in development of the nervous system.
- B. Although gastrulation is completely different in invertebrates and vertebrates, the formation of a neural tube is identical in the two types of animals.
- C. There is little similarity, since the neuroectoderm of invertebrates forms their nervous system with no further morphological changes, while in vertebrates, the neural tube forms a bundle of neurons running along the antero-posterior axis called the spinal cord.
- D. Although the invertebrate nervous system is a ventrally located nerve cord, and the vertebrate spinal cord is located dorsally, homologous genes play a role, and neurons are ultimately specified through a process of lateral inhibition in both cases.
Correct Answer: D
Rationale: Despite differences in the location of the neuroectoderm (ventral in Drosophila, dorsal in vertebrates), both systems share similarities in the genetic mechanisms underlying neural development. Homologous genes, such as those involved in lateral inhibition, play crucial roles in specifying neurons in both invertebrates and vertebrates. This highlights the evolutionary conservation of developmental processes despite morphological differences.
What happens at the synapse?
- A. The synapse physically joins two neurons.
- B. The nerve impulse is transmitted only from one neuron to another neuron.
- C. The presynaptic terminal submits a nerve impulse through the synaptic cleft to the receptor site on the postsynaptic cell.
- D. When a presynaptic cell releases excitatory neurotransmitters, the postsynaptic cell depolarizes enough to generate an action potential.
Correct Answer: C
Rationale: The synaptic transmission involves the presynaptic terminal sending impulses across the synaptic cleft.
What is a consequence related to rigidity?
- A. Shuffling gait
- B. Impaired handwriting
- C. Lack of postural stability
- D. Muscle soreness and pain
Correct Answer: A
Rationale: Rigidity contributes to a shuffling gait in Parkinson's disease