Nokea
To assess for a possible seizure disorder, the nurse should:
- A. Observe the patient for any involuntary movements or altered consciousness.
- B. Measure the patient's heart rate.
- C. Inspect the patient's skin for rashes.
- D. Check the patient's blood glucose levels.
Correct Answer: A
Rationale: Seizure disorders are assessed by observing for involuntary movements or altered consciousness. Heart rate, skin rashes, and blood glucose levels are unrelated to seizure assessment.
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Brown-Sequard syndrome develops with the following damage of the spinal cord:
- A. complete transversal
- B. anterior horns
- C. half transversal
- D. posterior horns
Correct Answer: C
Rationale: Half transversal is the correct answer because Brown-Sequard syndrome results from damage to one side of the spinal cord. This leads to ipsilateral motor paralysis and loss of proprioception, and contralateral loss of pain and temperature sensation due to the crossing of spinothalamic tract fibers.
The brain is protected by:
- A. the meninges.
- B. a cushion of fluid.
- C. the bony skull.
- D. All of the above.
Correct Answer: D
Rationale: The brain is protected by multiple layers of defense, including the meninges (protective membranes), cerebrospinal fluid (a cushioning fluid), and the bony skull. The meninges consist of three layersâ€â€dura mater, arachnoid mater, and pia materâ€â€that provide structural support and protection. Cerebrospinal fluid surrounds the brain and spinal cord, acting as a shock absorber. The skull provides a rigid barrier against physical injury. Together, these structures safeguard the brain from damage.
The disturbance of purposive movement in absence of paresis & dyscoordination suggests the presence of the following:
- A. dyslexia
- B. dysgnosia
- C. dyspraxia
- D. dysphasia
Correct Answer: C
Rationale: Dyspraxia is the correct answer because it is a disorder of motor planning and execution, where the individual has difficulty performing purposeful movements despite having the physical ability and desire to do so. This condition is not due to muscle weakness or incoordination but rather to a disruption in the brain's ability to plan and execute movements.
A technique that has proven to be helpful in training individuals with amnesia, where people are prevented - as far as possible - from making any errors while learning a new skill or new information is known as:
- A. Mnemonic training.
- B. Errorless learning.
- C. Aquistion learning.
- D. Prevention training.
Correct Answer: B
Rationale: Errorless learning is a training technique used to help individuals with amnesia acquire new skills or information without making mistakes. By minimizing errors during the learning process, this method enhances memory retention and reduces the likelihood of incorrect information being stored. Errorless learning is particularly effective for individuals with memory impairments, as it leverages their residual learning abilities and promotes successful skill acquisition.
A nurse counseling a patient diagnosed with dissociative identity disorder (DID) should understand that the assessment of highest priority is:
- A. risk for self-harm
- B. cognitive functioning
- C. identification of drug abuse
- D. readiness to reestablish identity or memory
Correct Answer: A
Rationale: The correct answer is A: risk for self-harm. In patients with DID, the primary concern is ensuring their safety due to the high risk of self-harm or suicide. Assessing this risk is crucial for immediate intervention to prevent harm. Choice B, cognitive functioning, may be important but is secondary to ensuring patient safety. Choice C, identification of drug abuse, is relevant but not as urgent as addressing the risk for self-harm. Choice D, readiness to reestablish identity or memory, is important but not as critical as ensuring the patient's safety. Therefore, assessing the risk for self-harm takes precedence in the care of a patient with DID.