Nokea
What is a normal response when assessing the pupillary light reflex?
- A. Pupils constrict in response to light and then dilate when light is removed.
- B. Pupils remain dilated regardless of light exposure.
- C. Pupils remain constricted regardless of light exposure.
- D. Pupils respond unevenly to light.
Correct Answer: A
Rationale: The normal pupillary light reflex involves constriction in response to light and dilation when light is removed. Uneven or absent responses are abnormal.
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Which cranial nerve lies in the junction between pons and medilla?
- A. abducent nerve (VI)
- B. facial nerve (VII)
- C. vestibulocochlear nerve (VIII)
- D. glossopharyngeal nerve (IX)
Correct Answer: A
Rationale: The abducent nerve (VI) emerges at the junction between the pons and medulla. It controls the lateral rectus muscle, which abducts the eye.
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.
Mr. Sands continues to be quiet and withdrawn several days after admission. Besides Raynaud phenomenon, he has generalized telangiectasis. He seldom initiates conversation, and although up ad lib, he rarely leaves his room. Which one of the following goals would be most important to develop in his nursing care plan?
- A. Provide for solitude and rest
- B. Protect from temperature extremes
- C. Enhance self-concept
- D. Move to a four-bed ward
Correct Answer: C
Rationale: Enhancing self-concept can improve social interaction and emotional well-being.
A patient arrives in the ER with blurred and double vision, muscle weakness, and intolerance of temperature changes. The physician suspects multiple sclerosis. What test would you expect the physician to do in order to confirm his or her suspicions?
- A. CBC with a very low WBC count.
- B. MRI with gadolinium showing demyelination of nerve fibers.
- C. Endocrine function study with a low growth hormone and high T3 and T4.
- D. Fasting glucose test with a result over 300 mg/dL.
Correct Answer: B
Rationale: MRI with gadolinium is used to identify demyelination, which is characteristic of multiple sclerosis.
As the manager in a long-term-care (LTC) facility, you are in charge of developing a standard plan of care for residents with Alzheimer's disease. Which of these nursing tasks is best to delegate to the LPN team leaders working in the facility?
- A. Check for improvement in resident memory after medication therapy is initiated.
- B. Use the Mini-Mental State Examination to assess residents every 6 months.
- C. Assist residents to toilet every 2 hours to decrease risk for urinary incontinence.
- D. Develop individualized activity plans after consulting with residents and family.
Correct Answer: C
Rationale: Toileting assistance is a routine task that can be effectively managed by LPNs.