Nokea
The nurse needs to detect the presence of ischemia in a client with tissue injury. Which of the following signs and symptoms may indicate the presence of ischemia?
- A. Signs of fatigue
- B. Signs of respiratory depression
- C. Absence of a peripheral pulse
- D. Heavy swelling in the injured area
Correct Answer: C
Rationale: Ischemia often results in the absence of a peripheral pulse due to restricted blood flow.
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In planning Mr. Smith's preoperative care to minimize the risk of an acute exacerbation, it will be most important to include
- A. discussion of postoperative care
- B. arrangements with dietary department to increase protein intake
- C. increased active and passive range-of-motion exercises
- D. time for Mr. Smith to share his feelings about the impending surgery
Correct Answer: C
Rationale: Exercise helps maintain joint function and reduces the risk of exacerbation.
Which specialized cell of the skin produces pigment?
- A. Keratinocyte
- B. Melanocyte
- C. Langerhans
- D. Horney
Correct Answer: B
Rationale: Melanocytes are the correct answer because they are specialized cells in the skin that produce melanin, the pigment responsible for skin color. Melanin protects the skin from harmful ultraviolet (UV) radiation by absorbing and dissipating the energy, thereby reducing DNA damage in skin cells. This function is crucial for preventing skin cancer and other UV-induced damage.
The presence of Bell's palsy suggests damage to the following cranial nerve:
- A. facial
- B. optic
- C. olfactory
- D. vestibular
Correct Answer: A
Rationale: Facial nerve is the correct answer because Bell's palsy is a condition characterized by the sudden weakness or paralysis of the facial muscles on one side of the face due to inflammation or damage to the facial nerve (cranial nerve VII). This results in symptoms such as drooping of the mouth, inability to close the eye, and loss of facial expression.
A diagnosis of a ruptured cerebral aneurysm has been made in a patient with manifestations of a stroke. The nurse anticipates which treatment option that would be considered for the patient?
- A. Hyperventilation therapy
- B. Surgical clipping of the aneurysm
- C. Administration of hyperosmotic agents
- D. Administration of thrombolytic therapy
Correct Answer: B
Rationale: Surgical clipping prevents further bleeding from a ruptured aneurysm
A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that suddenly started a short time ago. Assessment of the patient reveals increased blood pressure (168/94) and decreased heart rate (48/minute), diaphoreses, and flushing of the face and neck. What action should you take first?
- A. Administer the ordered acetaminophen (Tylenol).
- B. Check the Foley tubing for kinks or obstruction.
- C. Adjust the temperature in the patient's room.
- D. Notify the physician about the change in status.
Correct Answer: B
Rationale: Checking the Foley tubing is critical as it could indicate autonomic dysreflexia, a life-threatening condition in SCI patients.