Nokea
What is a consequence related to rigidity?
- A. Shuffling gait
- B. Impaired handwriting
- C. Lack of postural stability
- D. Muscle soreness and pain
Correct Answer: A
Rationale: Rigidity contributes to a shuffling gait in Parkinson's disease
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When testing the patient's cranial nerves, the nurse should:
- A. Perform specific tests for each nerve, such as asking the patient to smile or follow an object with their eyes.
- B. Measure the patient's blood glucose levels.
- C. Inspect the patient's joints for swelling.
- D. Check the patient's peripheral pulses.
Correct Answer: A
Rationale: Testing cranial nerves involves specific assessments for each nerve, such as facial movements (cranial nerve VII) or eye movements (cranial nerves III, IV, and VI). Blood glucose levels, joint swelling, and peripheral pulses are unrelated to cranial nerve testing.
Priority Decision: Before repositioning the patient on the side after a lumbar laminectomy, what should be the nurse's first action?
- A. Raise the head of the bed 30 degrees.
- B. Have the patient flex the knees and hips.
- C. Place a pillow between the patient's legs.
- D. Have the patient grasp the side rail on the opposite side of the bed.
Correct Answer: A
Rationale: Raising the head of the bed stabilizes the spine.
What is the best response to a patient with a right above-the-knee amputation asking about phantom limb pain?
- A. Phantom limb pain is not explained or predicted by any one theory.
- B. Phantom limb pain occurs because your body thinks your leg is still present.
- C. Phantom limb pain will not interfere with your activities of daily living.
- D. Phantom limb pain is not real pain, but remembered pain.
Correct Answer: A
Rationale: Phantom limb pain is a complex phenomenon not fully understood and requires careful explanation.
For a patient with a one-sided spinal injury, the nurse must be careful about the temperature of the bath water because the patient's temperature sensation is lost
- A. contralaterally below the injury
- B. ipsilaterally below the injury
- C. bilaterally below the injury
- D. contralaterally above the injury
Correct Answer: A
Rationale: Temperature sensation is lost contralaterally below the injury level.
You are supervising a senior nursing student who is caring for a patient with a right hemisphere stroke. Which action by the student nurse requires that you intervene?
- A. The student instructs the patient to sit up straight, resulting in the patient's puzzled expression.
- B. The student moves the patient's tray to the right side of her over-bed tray.
- C. The student assists the patient with passive range-of-motion (ROM) exercises.
- D. The student combs the left side of the patient's hair when the patient combs only the right side.
Correct Answer: A
Rationale: Right hemisphere strokes can impair spatial perception; instructions may need to be simplified or demonstrated.