Nokea
The right hand of a client with multiple sclerosis trembles severely whenever she attempts a voluntary action. She spills her coffee twice at lunch and cannot get her dress fastened securely. Which is the best legal documentation in nurses' notes of the chart for this client assessment?
- A. Has an intention tremor of the right hand.
- B. Right-hand tremor worsens with purposeful acts.
- C. Needs assistance with dressing and eating due to severe trembling and clumsiness.
- D. Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup.
Correct Answer: D
Rationale: Documenting the specific circumstances under which the tremor worsens provides a clear and accurate description of the client's condition.
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The vagus nerve
- A. Arises from the medulla as a single nerve
- B. Receives nucleus ambiguous fibres from the accessory nerve
- C. Supplies motor fibres to the diaphragm
- D. Supplies sensory fibres to the facial region
Correct Answer: B
Rationale: The vagus nerve receives motor fibers from the nucleus ambiguus, which also contributes to the accessory nerve. It innervates muscles of the pharynx and larynx.
Which of the following pathways is not concerned with posture and movement?
- A. Spinocerebellar
- B. Vestibulospinal
- C. Tractus solitarius
- D. ?
Correct Answer: C
Rationale: The tractus solitarius is involved in taste and visceral sensation, not posture and movement. The spinocerebellar and vestibulospinal tracts are involved in motor coordination and balance.
When assessing a patient's level of consciousness, which response would indicate a decreased level of consciousness?
- A. The patient is drowsy but can be easily aroused.
- B. The patient is alert and oriented.
- C. The patient responds quickly to verbal stimuli.
- D. The patient is fully awake and responsive.
Correct Answer: A
Rationale: A drowsy patient who can be easily aroused indicates a decreased level of consciousness. Alertness, quick responses, and full wakefulness are normal findings.
What neurotransmitter will result in constriction of the pupil?
- A. norepinephrine
- B. acetylcholine
- C. epinephrine
- D. serotonin
Correct Answer: B
Rationale: The correct answer is B: acetylcholine. Acetylcholine is the neurotransmitter responsible for causing constriction of the pupil. When acetylcholine binds to muscarinic receptors in the eye muscles, it triggers the muscles to contract, leading to pupil constriction. Norepinephrine (choice A) and epinephrine (choice C) are both involved in the fight-or-flight response and dilate the pupils. Serotonin (choice D) does not directly affect pupil constriction.
A patient learns that abdominal pain is originating from the liver. The nurse should explain to the patient that the impulses from receptors in the internal organs to the central nervous system are transmitted from which type of neurons?
- A. Interneurons
- B. Efferent neurons
- C. Somatic sensory neurons
- D. Visceral sensory neurons
Correct Answer: D
Rationale: Visceral sensory neurons transmit impulses from internal organs, such as the liver, to the central nervous system. Somatic sensory neurons transmit impulses from the skin and skeletal muscles, while efferent neurons carry motor impulses. Interneurons are found entirely within the central nervous system. This distinction is important for understanding pain pathways.