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To assess the Glasgow Coma Scale (GCS), the nurse needs to evaluate:
- A. Eye opening, verbal response, and motor response.
- B. Heart rate, blood pressure, and temperature.
- C. Pupil size, reaction to light, and accommodation.
- D. Skin turgor, moisture, and temperature.
Correct Answer: A
Rationale: The Glasgow Coma Scale (GCS) assesses a patient's level of consciousness based on eye opening, verbal response, and motor response. It is a standardized tool used in neurological assessments.
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The patient with apraxia cannot:
- A. name his fingers
- B. carry out an imagined act
- C. draw simple diagrams
- D. speak fluently
Correct Answer: B
Rationale: Carry out an imagined act is the correct answer because apraxia is a motor disorder characterized by the inability to perform purposeful movements, despite having the physical ability and desire to do so. This condition results from damage to the parietal lobe or other areas involved in motor planning.
Which assessment finding best supports the diagnosis of dissociative amnesia with fugue? The patient states:
- A. I cannot recall why I'm living in this town.
- B. I feel as if I'm living in a fuzzy dream state.
- C. I feel like different parts of my body are at war.
- D. I feel very anxious and worried about my problems.
Correct Answer: A
Rationale: The correct answer is A because the key feature of dissociative amnesia with fugue is the inability to remember important personal information. In this case, the patient cannot recall why they are living in the current town, indicating a significant gap in memory. Choice B describes a feeling of disorientation, not memory loss. Choice C suggests dissociative identity disorder, not dissociative amnesia. Choice D focuses on anxiety, which is not a primary symptom of dissociative amnesia with fugue.
Schizophrenia and Parkinson's disease are both linked to changes in which neurotransmitter?
- A. serotonin
- B. glutamate
- C. dopamine
- D. acetylcholine
Correct Answer: C
Rationale: Dopamine is a neurotransmitter that plays a critical role in regulating mood, motivation, and movement. Schizophrenia is associated with excessive dopamine activity in certain brain regions, leading to symptoms like hallucinations and delusions. In contrast, Parkinson's disease is linked to a deficiency of dopamine in the basal ganglia, resulting in motor symptoms such as tremors and rigidity. Both conditions highlight the importance of dopamine in brain function and the consequences of its dysregulation.
Which number represents the medulla oblongata? (Figure 3)
- A. 1
- B. 2
- C. 5
- D. 8
Correct Answer: D
Rationale: The number 8 represents the medulla oblongata because it is the lower part of the brainstem that controls vital autonomic functions such as heart rate, breathing, and blood pressure. The medulla oblongata is essential for maintaining life and ensuring the proper functioning of the cardiovascular and respiratory systems.
When assessing the patient's ability to perform fine motor tasks, the nurse should:
- A. Ask the patient to perform tasks such as buttoning a shirt or writing a sentence.
- B. Measure the patient's blood pressure.
- C. Inspect the patient's gait and balance.
- D. Check the patient's oral hygiene.
Correct Answer: A
Rationale: Fine motor skills are assessed by tasks like buttoning a shirt or writing. Blood pressure, gait, and oral hygiene are unrelated to fine motor assessment.