Nokea
The temperature & pin sense loss usually develops with disease in:
- A. anterior horns of spinal cord
- B. posterior horns of spinal cord
- C. lateral horns of spinal cord
- D. posterior columns of spinal cord
Correct Answer: B
Rationale: Posterior horns of the spinal cord are the correct answer because they are involved in processing sensory information, including pain and temperature. Damage to this area disrupts the transmission of these sensory signals, leading to a loss of temperature and pinprick sensation while preserving other sensory modalities.
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A patient taking ibuprofen (Motrin) for treatment of OA has good pain relief but is experiencing increased dyspepsia and nausea with the drug's use. The nurse consults the patient's primary care provider about doing what?
- A. Adding misoprostol (Cytotec) to the patient's drug regimen
- B. Substituting naproxen (Naprosyn) for the ibuprofen (Motrin)
- C. Returning to the use of acetaminophen but at a dose of 5 g/day instead of 4 g/day
- D. Administering the ibuprofen with antacids to decrease the gastrointestinal (GI) irritation
Correct Answer: A
Rationale: Misoprostol protects the GI tract.
The nurse practitioner is assessing an adult patient with a seizure disorder that is well controlled on phenytoin (Dilantin). What new finding indicates that a phenytoin drug level assessment is needed?
- A. Hypertrophic gums
- B. Vitamin D supplements
- C. BP 125/78 mmHg and pulse 95 bpm
- D. Flat affect and anxiety
Correct Answer: D
Rationale: The correct answer is D because a flat affect and anxiety can indicate potential phenytoin toxicity, which warrants a drug level assessment. Phenytoin toxicity can manifest as neurological symptoms such as mood changes and cognitive impairment. Options A and B are unrelated to phenytoin levels. Option C indicates normal vital signs and is not a specific indicator of phenytoin toxicity.
What is the priority nursing diagnosis for a patient experiencing a migraine headache?
- A. Acute Pain related to biologic and chemical factors
- B. Anxiety related to change in or threat to health status
- C. Hopelessness related to deteriorating physiological condition
- D. Risk for Side Effects related to medical therapy
Correct Answer: A
Rationale: Migraine headaches are primarily characterized by severe pain, making Acute Pain the priority.
How can the nurse examine the client for stiffness and rigidity of the neck?
- A. By positioning the client flat on the bed for at least three hours.
- B. By moving the head and chin of the client towards the chest.
- C. By asking the client to bend and pick up small and large objects on the floor.
- D. By introducing a painful stimulus on the neck.
Correct Answer: B
Rationale: This movement checks for neck stiffness indicative of neurological issues.
A patient who had a below-the-knee amputation is to be fitted with a temporary prosthesis. It is most important for the nurse to teach the patient to do what?
- A. Inspect the residual limb daily for irritation.
- B. Apply an elastic shrinker before applying the prosthesis.
- C. Perform range-of-motion (ROM) exercises to the affected leg four times a day.
- D. Apply alcohol to the residual limb every morning and evening to toughen the skin.
Correct Answer: B
Rationale: Shrinkers help mold the residual limb for the prosthesis.