Nokea
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.
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Which of the following is the correct sequence in a typical reflex arc:
- A. effector, afferent neuron, integration centre, efferent neuron, receptor
- B. receptor, afferent neuron, integration centre, efferent neuron, effector
- C. effector, efferent neuron, integration centre, afferent neuron, receptor
- D. receptor, efferent neuron, integration centre, afferent neuron, effector
Correct Answer: B
Rationale: The correct sequence in a reflex arc is: receptor detects the stimulus, afferent neuron transmits the signal to the integration center, efferent neuron carries the response signal, and effector produces the response. Therefore, B is the correct answer.
When assessing a patient's orientation, the nurse should:
- A. Ask the patient questions about their name, location, and the date.
- B. Measure the patient's temperature.
- C. Inspect the patient's skin color.
- D. Check the patient's pulse rate.
Correct Answer: A
Rationale: Orientation is assessed by asking the patient about their name, location, and the date. Temperature, skin color, and pulse rate are unrelated to orientation.
When the nurse talks with a client with multiple sclerosis who has slurred speech, which nursing intervention is contraindicated?
- A. Encouraging the client to speak slowly
- B. Encouraging the client to speak distinctly
- C. Asking the client to repeat indistinguishable words
- D. Asking the client to speak louder when tired
Correct Answer: D
Rationale: Asking the client to speak louder when tired can exacerbate fatigue and frustration, which is counterproductive for someone with MS.
The healthcare provider is planning care for a patient diagnosed with multiple sclerosis (MS). Which of the following is the priority intervention?
- A. Advise the patient to drink liquids through a straw
- B. Monitor the patient's temperature to avoid overheating
- C. Teach the patient's family how to meet the patient's needs
- D. Encourage bed rest in order to conserve strength
Correct Answer: B
Rationale: Overheating can exacerbate MS symptoms, so monitoring temperature is a priority to prevent symptom flare-ups.
Which of the following nursing interventions should be done in the case of a client who has a head injury obtained from being thrown off of a motorcycle?
- A. Assess LOC every hour or more often if needed
- B. Put the code cart outside the client's room
- C. Keep the client quiet in bed
- D. Allow one visitor at a time
Correct Answer: A
Rationale: Frequent assessments of LOC are critical to detect worsening neurological status.