Nokea
The nurse is providing care for an 87-year-old woman who is recovering from a cerebral vascular accident. Which precaution should the nurse take after noting the patient has a positive Romberg test?
- A. Institute fall-risk precautions.
- B. Provide small, frequent meals.
- C. Request a footboard and splints.
- D. Darken the room and reduce stimuli.
Correct Answer: A
Rationale: A positive Romberg test indicates impaired balance and proprioception, increasing the risk of falls. Fall-risk precautions, such as using a gait belt and ensuring a safe environment, are essential. Small meals, footboards, and reducing stimuli are not directly related to balance issues.
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All of the following are branches of the ophthalmic division of the trigeminal nerve EXCEPT:
- A. Lacrimal nerve
- B. Infraorbital nerve
- C. Supraorbital nerve
- D. Infratrochlear nerve
Correct Answer: B
Rationale: The infraorbital nerve is a branch of the maxillary division (V2) of the trigeminal nerve, not the ophthalmic division (V1). It supplies sensation to the lower eyelid, cheek, and upper lip.
True statements about aldosterone include:
- A. it increases the amount of Na+-K+ ATPase in the target cells
- B. it reduces the sodium content of the sweat
- C. it increases the acidity of urine
- D. all above
Correct Answer: D
Rationale: Aldosterone increases Na+-K+ ATPase activity in target cells, promoting sodium reabsorption and potassium excretion. It also reduces sodium loss in sweat and increases urine acidity by promoting hydrogen ion excretion. These actions help regulate electrolyte balance and blood pressure.
The limbic system includes the:
- A. amygdala, hypothalamus, hippocampus
- B. hypothalamus, medulla, hippocampus
- C. hippocampus, pons, thalamus
- D. cerebellum, pons, hypothalamus
Correct Answer: A
Rationale: The limbic system is a group of brain structures involved in emotion, memory, and motivation. It includes the amygdala, which processes fear and emotional responses; the hypothalamus, which regulates hormones and homeostasis; and the hippocampus, which is essential for forming and retrieving memories. These structures work together to integrate emotional and cognitive processes, playing a key role in behavior and survival.
The nurse instructs a client who has a neurological deficit regarding nutrition and diet. What should the client do?
- A. Eat two large meals instead of frequent small meals.
- B. Consume a diet low in fiber.
- C. Chew foods quickly.
- D. Be sure to take fluids frequently.
Correct Answer: D
Rationale: Staying hydrated is crucial for clients with neurological deficits to prevent constipation and urinary tract infections.
Application of RICE (rest, ice, compression, and elevation) is indicated for initial management of which type of injury?
- A. Muscle spasms
- B. Sprains and strains
- C. Repetitive strain injury
- D. Dislocations and subluxations
Correct Answer: B
Rationale: RICE is effective for managing acute soft tissue injuries like sprains and strains.