Nokea
What is the priority nursing diagnosis for a patient experiencing a migraine headache?
- A. Acute Pain related to biologic and chemical factors
- B. Anxiety related to change in or threat to health status
- C. Hopelessness related to deteriorating physiological condition
- D. Risk for Side Effects related to medical therapy
Correct Answer: A
Rationale: Migraine headaches are primarily characterized by severe pain, making Acute Pain the priority.
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A 70-year-old patient is admitted after falling from his roof. He has a spinal cord injury at the C7 level. What findings during the assessment identify the presence of spinal shock?
- A. Paraplegia with a flaccid paralysis
- B. Tetraplegia with total sensory loss
- C. Total hemiplegia with sensory and motor loss
- D. Spastic tetraplegia with loss of pressure sensation
Correct Answer: A
Rationale: Flaccid paralysis below the level of injury indicates spinal shock.
The change in electrical charge that occurs in a neuron when a nerve impulse is transmitted is known as the:
- A. action potential
- B. synaptic change
- C. refractory period
- D. ionic charge
Correct Answer: A
Rationale: An action potential is the rapid change in electrical charge that occurs in a neuron when a nerve impulse is transmitted. This process involves the depolarization of the neuron's membrane, where sodium ions rush into the cell, followed by repolarization, where potassium ions exit the cell. The action potential is the basis for neural communication and allows signals to travel quickly along the axon to the synapse, where neurotransmitters are released to communicate with other neurons.
Patients who work in settings that require repetition of the same hand movements over a long period of time have an increased risk for which of the following disorders?
- A. Osteomyelitis.
- B. Osteoporosis.
- C. Carpal tunnel syndrome.
- D. Fracture of the overused area.
Correct Answer: C
Rationale: Repetitive strain can lead to median nerve compression causing carpal tunnel syndrome.
MRS. Post is being discharged tomorrow on a regimen of prednisone and aspirin to control her symptoms of systemic lupus erythematosus. She should be told to call her physician immediately if which one of the following occurs?
- A. Missed menstrual period
- B. Inability to take oral medications because of vomiting
- C. Temperature elevated to 99.6°F
- D. Ankle edema
Correct Answer: B
Rationale: Vomiting can interfere with medication absorption and effectiveness.
Within how many hours does tissue plasminogen activator (TPA) need to be given to be most successful for a client with an ischemic stroke?
- A. 6 hours
- B. 3 hours
- C. 8 hours
- D. 10 hours
Correct Answer: B
Rationale: TPA is most effective when administered within 3 hours of stroke onset.