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To assess a patient's ability to follow commands, the nurse should:
- A. Ask the patient to perform simple tasks, such as closing their eyes or squeezing their hand.
- B. Measure the patient's body temperature.
- C. Inspect the patient's skin for abnormalities.
- D. Check the patient's respiratory rate.
Correct Answer: A
Rationale: Following commands is assessed by asking the patient to perform simple tasks. Body temperature, skin inspection, and respiratory rate are unrelated to this assessment.
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A patient has an atherosclerotic plaque in the middle cerebral artery. What does the nurse recognize about this patient's situation?
- A. Assessment will reveal distended jugular veins.
- B. Cerebral circulation may be maintained through the circle of Willis.
- C. The patient will develop a loss of temporal and parietal lobe function.
- D. Increased pressure in the middle cerebral artery will back up into the vertebral arteries.
Correct Answer: B
Rationale: The circle of Willis can maintain cerebral circulation if one artery is compromised.
Which of the following can NOT be prevented with a vaccine?
- A. tetanus
- B. pneumococcal meningitis
- C. meningococcal meningitis
- D. listeriosis
Correct Answer: D
Rationale: The correct answer is D: listeriosis. Listeriosis is caused by a bacterium and there is currently no vaccine available for it. Tetanus, pneumococcal meningitis, and meningococcal meningitis, on the other hand, are all preventable with vaccines. Tetanus is prevented by the DTaP vaccine, pneumococcal meningitis by the pneumococcal conjugate vaccine, and meningococcal meningitis by the meningococcal vaccine. Therefore, listeriosis is the only condition among the options that cannot be prevented with a vaccine.
A young male client visits a nurse with a complaint of chronic tension headaches. Which of the following is the most appropriate nursing instruction to manage the client?
- A. Instructing the client to monitor for signs of bruising or bleeding
- B. Suggesting eating and swallowing techniques that reduce the potential for aspiration
- C. Counseling on alternate therapies
- D. Advising the client to change sleeping positions frequently
Correct Answer: C
Rationale: Alternate therapies, such as relaxation techniques, can help manage tension headaches.
A patient becomes startled when the alarm rings for a fire drill. After reassuring the patient that there is no danger, an assessment is completed. Which finding may be related to a sympathetic response?
- A. Wheezing
- B. Confusion
- C. Incontinence
- D. Diminished bowel sounds
Correct Answer: D
Rationale: A sympathetic response, or fight-or-flight reaction, includes decreased gastrointestinal activity, leading to diminished bowel sounds. Wheezing, confusion, and incontinence are not typical sympathetic responses. Understanding the autonomic nervous system helps explain physiological changes during stress.
Injury to which segment of the spine results in damage to the chest and abdominal muscles?
- A. cervical
- B. thoracic
- C. lumbar
- D. sacral
Correct Answer: B
Rationale: Injury to the thoracic spine (T1-T12) can affect the chest and abdominal muscles, as this region of the spinal cord controls motor and sensory functions for the upper body. Damage here can lead to paralysis or weakness in these areas.