Nokea
The patient with multiple sclerosis tells the nursing assistant that after physical therapy she is too tired to take a bath. What is your priority nursing diagnosis at this time?
- A. Fatigue related to disease state
- B. Activity Intolerance due to generalized weakness
- C. Impaired Physical Mobility related to neuromuscular impairment
- D. Self-care Deficit related to fatigue and neuromuscular weakness
Correct Answer: A
Rationale: Fatigue is a common symptom in MS and is directly indicated by the patient's statement.
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Regarding the blood supply of the cerebral cortex
- A. Middle cerebral is contralateral arm, leg and speech areas
- B. Anterior cerebral is contralateral leg, micturition and defaecation
- C. Middle cerebral is ipsilateral arm, face and vision
- D. Posterior cerebral is ipsilateral vision
Correct Answer: B
Rationale: The anterior cerebral artery supplies the medial surface of the brain, including areas responsible for motor and sensory functions of the contralateral leg. It also influences micturition and defecation.
Which of the following would the nurse assess first when Joe arrives in the emergency room?
- A. Movement of fingers
- B. Pain sensation in legs
- C. Respiratory rate
- D. Temperature sensation in arms
Correct Answer: C
Rationale: Respiratory function is prioritized in spinal injuries.
The brain and spinal cord are the organs of the ________ .
- A. CNS
- B. PNS
- C. ANS
- D. CSF
Correct Answer: A
Rationale: The brain and spinal cord are the primary organs of the central nervous system (CNS). The CNS is responsible for processing and integrating information received from the peripheral nervous system (PNS). The autonomic nervous system (ANS) is a division of the PNS, and cerebrospinal fluid (CSF) is a protective fluid surrounding the CNS. Therefore, CNS is the correct answer as it directly refers to the brain and spinal cord.
A patient diagnosed with a somatic symptom disorder has the nursing diagnosis: Interrupted family processes, related to patient's disabling symptoms as evidenced by the spouse and children assuming roles and tasks that previously belonged to patient. An appropriate outcome is that the patient will:
- A. assume roles and functions of the other family members.
- B. demonstrate a resumption of former roles and tasks.
- C. focus energy on problems occurring in the family.
- D. rely on family members to meet his or her personal needs.
Correct Answer: B
Rationale: The correct answer is B: demonstrate a resumption of former roles and tasks. This outcome implies that the patient will regain the ability to fulfill their own roles and tasks within the family, indicating improvement in the interrupted family processes. This aligns with the goal of promoting the patient's independence and reducing the burden on other family members.
Choice A is incorrect because having the patient assume roles and functions of other family members does not address the underlying issue of the patient's somatic symptom disorder and may lead to further dysfunction within the family.
Choice C is incorrect as it suggests the patient should focus on problems in the family, which may not directly address the interrupted family processes related to the patient's symptoms.
Choice D is incorrect as it promotes dependency on family members to meet the patient's personal needs, which does not encourage the patient to regain their former roles and tasks within the family.
Which of the following receptors does not span the cell membrane 7 times
- A. beta-Adrenergic receptor
- B. Rhodopsin
- C. 5-HTic receptor
- D. Mineralocorticoid receptor
Correct Answer: D
Rationale: The mineralocorticoid receptor is an intracellular receptor that does not span the cell membrane. It belongs to the steroid hormone receptor family and acts as a transcription factor after binding to its ligand. In contrast, beta-adrenergic receptors, rhodopsin, 5-HTic receptors, and LH receptors are G-protein-coupled receptors (GPCRs) that span the membrane seven times.