Nokea
The nursing assistant reports to you, the RN, that the patient with myasthenia gravis (MG) has an elevated temperature (102.2°F), heart rate of 120/minute, rise in blood pressure (158/94), and was incontinent of urine and stool. What is your best first action at this time?
- A. Administer an acetaminophen suppository.
- B. Notify the physician immediately.
- C. Recheck vital signs in 1 hour.
- D. Reschedule patient's physical therapy.
Correct Answer: B
Rationale: These symptoms could indicate a myasthenic crisis, necessitating immediate medical evaluation.
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Nursing students are doing a class presentation on stroke. What is the term they would use for deficits in articulation?
- A. Aphasia
- B. Nystagmus
- C. Dysarthria
- D. Dystonia
Correct Answer: C
Rationale: Dysarthria refers to difficulty in articulating words due to muscle weakness or incoordination, often caused by stroke. Aphasia is a language disorder, nystagmus is involuntary eye movement, and dystonia is a movement disorder characterized by sustained muscle contractions.
The autonomic nervous system includes any of the following EXCEPT:
- A. hypothalamus
- B. paravertebral sympathetic trunk
- C. vagal nerve
- D. cerebral cortex
Correct Answer: D
Rationale: Cerebral cortex is the correct answer because the autonomic nervous system (ANS) primarily consists of the hypothalamus, brainstem, and peripheral nerves, which regulate involuntary bodily functions. The cerebral cortex, however, is involved in higher cognitive functions and voluntary motor control, and is not part of the ANS.
What are the two branches of the autonomic nervous system?
- A. endocrine and exocrine
- B. upper and lower
- C. sympathetic and parasympathetic
- D. central and peripheral
Correct Answer: C
Rationale: The autonomic nervous system (ANS) regulates involuntary bodily functions and is divided into the sympathetic nervous system, which activates the 'fight or flight' response, and the parasympathetic nervous system, which promotes 'rest and digest' activities. These two branches work in opposition to maintain homeostasis.
How can the nurse assist the patient and family in coping with the long-term effects of a stroke?
- A. Informing family members that the patient will need assistance with almost all ADLs
- B. Explaining that the patient's prestroke behavior will return as improvement progresses
- C. Encouraging the patient and family members to seek assistance from family therapy or stroke support groups
- D. Helping the patient and family to understand the significance of residual stroke damage to promote problem solving and planning
Correct Answer: C
Rationale: Support groups and understanding residual damage aid in long-term adaptation to stroke effects
Which of these patients in the neurologic ICU will be best to assign to an RN who has floated from the medical unit?
- A. A 26-year-old patient with a basilar skull fracture who has clear drainage coming out of the nose
- B. A 42-year-old patient admitted several hours ago with a headache and diagnosed with a ruptured berry aneurysm
- C. A 46-year-old patient who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due
- D. A 65-year-old patient with an astrocytoma who has just returned to the unit after having a craniotomy
Correct Answer: C
Rationale: A stable patient receiving antibiotics is more appropriate for an RN floating from another unit.