Nokea
The presence of ptosis suggests damage to cranial nerve:
- A. IV
- B. V
- C. III
- D. VII
Correct Answer: C
Rationale: Cranial nerve III (oculomotor nerve) is the correct answer because it innervates the levator palpebrae superioris muscle, which is responsible for elevating the eyelid. Damage to this nerve results in ptosis, or drooping of the eyelid, along with other symptoms such as diplopia and impaired eye movement.
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The son of your 80-year-old female patient expresses concern about the mother's cognitive mental status. You tell the patient a list of three items and have the patient repeat them to check initial understanding. By having the patient repeat the three items after 5 minutes pass, you are assessing what cognitive function?
- A. Judgment
- B. Attention
- C. Memory
- D. Abstract reasoning
Correct Answer: C
Rationale: Asking the patient to repeat items after a delay assesses short-term memory. Judgment, attention, and abstract reasoning are evaluated through different cognitive tests, such as problem-solving tasks or interpreting proverbs.
Which of the following would describe the discomfort experienced by a client with a tension headache?
- A. A heavy feeling over the frontal region
- B. and sensitivity to light
- C. Pressure or steady constriction on both sides of the head
- D. Headache and temporary unilateral paralysis
Correct Answer: B
Rationale: Tension headaches often feel like a tight band around the head.
To assist a patient diagnosed with a somatic system disorder, a nursing intervention of high priority is to:
- A. imply that somatic symptoms are not real.
- B. help the patient suppress feelings of anger.
- C. shift the focus from somatic symptoms to feelings.
- D. investigate each physical symptom as soon as it is reported.
Correct Answer: C
Rationale: Rationale for Choice C: Shifting the focus from somatic symptoms to feelings is crucial as it helps address the underlying emotional factors contributing to the somatic system disorder. By exploring the patient's emotions and addressing them, the nurse can help the patient gain insight into their condition and potentially reduce the somatic symptoms. This intervention promotes holistic care by addressing both physical and emotional aspects of the disorder.
Summary of other choices:
A: Implying that somatic symptoms are not real can invalidate the patient's experience and hinder therapeutic progress.
B: Helping the patient suppress feelings of anger can lead to emotional repression and exacerbate somatic symptoms.
D: Investigating each physical symptom as soon as it is reported may overlook the emotional root causes of the somatic system disorder.
The following signs occur in ipsilateral interruption of the cervical sympathetic trunk:
- A. enophthalmos
- B. ptosis
- C. vasodilatation in the skin of the face
- D. All above
Correct Answer: D
Rationale: Interruption of the cervical sympathetic trunk leads to Horner's syndrome, characterized by ipsilateral ptosis (drooping eyelid), miosis (pupil constriction), and anhidrosis (lack of sweating). Enophthalmos (sunken eye) and vasodilatation in the facial skin may also occur due to loss of sympathetic tone.
The nurse is preparing a client with multiple sclerosis (MS) for discharge from the hospital to home. The nurse should tell the client:
- A. You will need to accept the necessity for a quiet and inactive lifestyle.
- B. Keep active, use stress reduction strategies, and avoid fatigue.
- C. Follow good health habits to change the course of the disease.
- D. Practice using the mechanical aids that you will need when future disabilities arise.
Correct Answer: B
Rationale: Encouraging activity, stress reduction, and fatigue management is essential for maintaining quality of life in MS. A completely inactive lifestyle is not recommended.