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What is the major focus for care today for a patient who is 1 day post-operative after a left below-the-knee amputation?
- A. To attain pain control for phantom pain.
- B. To monitor for signs of sufficient tissue perfusion.
- C. To assist the patient to ambulate as soon as possible.
- D. To elevate the residual limb when the patient is supine.
Correct Answer: B
Rationale: Ensuring adequate tissue perfusion is critical in the immediate post-operative period to prevent complications.
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To assess the patient's deep tendon reflexes, the nurse should:
- A. Use a reflex hammer to test responses in the biceps, triceps, and patellar tendons.
- B. Measure the patient's temperature.
- C. Inspect the patient's gait.
- D. Check the patient's level of consciousness.
Correct Answer: A
Rationale: Deep tendon reflexes are tested using a reflex hammer to elicit responses in specific tendons. Temperature, gait, and level of consciousness are unrelated to reflex testing.
The cerebellum, ________ portion of the brain, is located below the occipital lobes of the cerebrum.
- A. the largest
- B. the second largest
- C. the third largest
- D. the smallest
Correct Answer: B
Rationale: The cerebellum is the second largest portion of the brain, located below the occipital lobes of the cerebrum. It plays a crucial role in coordinating voluntary movements, balance, and posture. While the cerebrum is the largest part of the brain, the cerebellum is smaller but still significant in size and function. Therefore, the second largest is the correct answer.
Which finding may suggest a problem with the patient's proprioception?
- A. Difficulty standing with eyes closed or swaying when standing still.
- B. Steady gait and normal balance.
- C. Clear, intact sensation in all extremities.
- D. Normal muscle strength and coordination.
Correct Answer: A
Rationale: Proprioception issues are indicated by difficulty standing with eyes closed or swaying. Steady gait, intact sensation, and normal strength are normal findings.
Which intervention should the nurse delegate to the licensed practical nurse (LPN) when caring for a patient following an acute stroke?
- A. Assess the patient's neurologic status.
- B. Assess the patient's gag reflex before beginning feeding.
- C. Administer ordered antihypertensives and platelet inhibitors.
- D. Teach the patient's caregivers strategies to minimize unilateral neglect.
Correct Answer: C
Rationale: Administering medications is typically within the scope of practice for LPNs
A patient with a fractured femur experiences the complication of malunion. The nurse recognizes that what happens with this complication?
- A. The fracture heals in an unsatisfactory position.
- B. The fracture fails to heal properly despite treatment.
- C. Fracture healing progresses more slowly than expected.
- D. Loss of bone substances occurs as a result of immobilization.
Correct Answer: A
Rationale: Malunion refers to a healed fracture in an incorrect alignment or position.