Nokea
To test for stereognosis you would
- A. Have the person close his or her eyes, then raise the person's arm and ask the person to describe its location.
- B. Touch the person with a tuning fork
- C. Place a coin in the person's hand and ask him or her to identify it.
- D. Touch the person with a cold object
Correct Answer: C
Rationale: Stereognosis is the ability to perceive and recognize the form of an object using touch. To test for stereognosis, place a familiar object, such as a coin, in the patient's hand and ask them to identify it with their eyes closed. This assesses the sensory cortex's ability to interpret tactile sensations.
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A nurse assessing a patient diagnosed with a somatic system disorder is most likely to note that the patient:
- A. readily sees a relationship between symptoms and interpersonal conflicts.
- B. rarely derives personal benefit from the symptoms.
- C. has little difficulty communicating emotional needs.
- D. has unmet needs related to comfort and activity.
Correct Answer: D
Rationale: The correct answer is D because patients with somatic system disorders often have unmet needs related to comfort and activity. These patients may focus on physical symptoms to express underlying emotional distress or seek attention. Choice A is incorrect because patients with somatic disorders often struggle to see a relationship between symptoms and psychological conflicts. Choice B is incorrect because patients with somatic disorders may derive secondary gain from their symptoms. Choice C is incorrect because patients with somatic disorders often have difficulty expressing emotional needs.
Which of the following actions should the nurse perform before a client with impaired physical mobility gets up?
- A. Use parallel bars or a walker
- B. Apply an abdominal binder
- C. Use incontinence pads
- D. Use footboard
Correct Answer: B
Rationale: An abdominal binder supports the trunk and aids stability.
Autonomic dysreflexia can best be described as a
- A. serious complication occurring in patients with cord damage below the T-6 level
- B. frequent cause of cerebral hemorrhage and myocardial infarction
- C. normal sequelae of spinal cord injury
- D. sudden exaggerated sympathetic discharge
Correct Answer: D
Rationale: Autonomic dysreflexia involves an exaggerated sympathetic response in spinal cord injury patients.
One criterion identified by the American College of Rheumatology for a diagnosis of fibromyalgia is
- A. Fiber atrophy found on muscle biopsy
- B. Elimination of all other causes of musculoskeletal pain
- C. The presence of the manifestations of chronic fatigue syndrome
- D. The elicitation of pain on palpation of at least 11 of 18 identified tender points
Correct Answer: D
Rationale: Tender points are diagnostic for fibromyalgia.
Priority Decision: During assessment of a patient with a spinal cord injury, the nurse determines that the patient has a poor cough with diaphragmatic breathing. Based on this finding, what should be the nurse's first action?
- A. Institute frequent turning and repositioning
- B. Use tracheal suctioning to remove secretions
- C. Assess lung sounds and respiratory rate and depth
- D. Prepare the patient for endotracheal intubation and mechanical ventilation
Correct Answer: C
Rationale: Assessment ensures proper diagnosis before intervention.