Nokea
The nurse notes in the patient's medical history that the patient has a positive Romberg test. Which of the following nursing diagnoses is appropriate?
- A. Acute pain related to physical injury agent (hyper-reflexia and spasm)
- B. Risk for falls as evidenced by impaired mobility
- C. Risk for autonomic dysreflexia as evidenced by spasm
- D. Ineffective thermoregulation related to inactivity
Correct Answer: B
Rationale: A positive Romberg test indicates that the patient has difficulty maintaining balance with the eyes closed. The Romberg does not test for autonomic dysreflexia, thermoregulation, or hyper-reflexia.
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The nurse is developing a plan of care for a patient with dysfunction of the cerebellum. Which of the following goals of care should the nurse include?
- A. Prevent falls.
- B. Stabilize mood.
- C. Enhance swallowing ability.
- D. Improve short-term memory.
Correct Answer: A
Rationale: Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing ability.
The nurse is admitting a patient with a head injury who is acutely confused. Which of the following actions should the nurse take?
- A. Ask family members about the patient's health history.
- B. Ask leading questions to assist in obtaining health data.
- C. Wait until the patient is better oriented to ask questions.
- D. Obtain only the physiologic neurological assessment data.
Correct Answer: A
Rationale: When admitting a patient with confusion, the nurse should obtain health history information from others who have knowledge about the patient's health to obtain accurate data. Waiting until the patient is oriented or obtaining only physiological data will result in incomplete assessment data, this could adversely affect decision-making about treatment. Asking leading questions may result in inaccurate or incomplete information.
The nurse is completing a neurological assessment with a patient. Which of the following assessments is the most sensitive indicator of a change in neurological status?
- A. Level of consciousness
- B. Cognition and thought content
- C. Mood and affect
- D. General appearance and behaviour
Correct Answer: A
Rationale: Level of consciousness (LOC) is the most sensitive indicator of changes in neurological status.
Which a patient who has peripheral nerve dysfunction? of the following information about an older-adult patient is most important for the admitting nurse to report to the patient's health care provider?
- A. Triceps reflex response graded at 1/5
- B. Recent unintended weight loss of 9.1 kg
- C. Patient complaint of persistent difficulty in falling asleep
- D. Orthostatic drop in systolic blood pressure of 10 mm Hg
Correct Answer: B
Rationale: Although changes in appetite are normal with aging, a 9.1 kg weight loss requires further investigation. Orthostatic drops in blood pressure, changes in sleep patterns, and slowing of reflexes are normal changes in aging.
The following prescriptions are received for an unconscious patient admitted to the emergency department (ED) with a head injury as result of an automobile accident. Which of the following prescriptions should the nurse question?
- A. Obtain radiographs of the skull and spine.
- B. Prepare the patient for lumbar puncture.
- C. Send for computed tomography (CT) scan.
- D. Perform neurologic checks every 15 minutes.
Correct Answer: B
Rationale: After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial pressure, which could lead to herniation of the brain with lumbar puncture. The other orders are appropriate.