Nokea
What kind of loss does the nurse recognize this to be?
- A. Delirium
- B. Memory loss in AD
- C. Normal forgetfulness
- D. Memory loss in mild cognitive impairment
Correct Answer: C
Rationale: Forgetting names and birthdays is typical of normal forgetfulness
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A laminectomy and spinal fusion are performed on a patient with a herniated lumbar intervertebral disc. During the postoperative period, which finding is of most concern to the nurse?
- A. Paralytic ileus
- B. Urinary incontinence
- C. Greater pain at the graft site than at the lumbar incision site
- D. Leg and arm movement and sensation unchanged from preoperative status
Correct Answer: B
Rationale: Urinary incontinence may indicate nerve damage.
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.
A client who has a musculoskeletal problem is being discharged after a few days of hospital care. Why should the nurse consider factors related to the home environment while determining a plan for the continued rehabilitation of the client?
- A. To include additional care for clients who lack the basic amenities at home.
- B. To determine the client's access to the nearest drugstore.
- C. To modify the client's living arrangements or other accommodation changes.
- D. To determine if the client would continue with the self-care.
Correct Answer: D
Rationale: Understanding the home environment ensures the client can continue their rehabilitation effectively.
The cutaneous innervation of the ear
- A. Is the lesser auricular nerve
- B. Involves the dermatome of C3
- C. Includes the zygomaticotemporal branch of the trigeminal nerve
- D. Includes the vagus
Correct Answer: D
Rationale: The vagus nerve (X) provides sensory innervation to the external auditory meatus and part of the ear. This is important in diagnosing referred pain from the ear.
The nurse is caring for a client with ICP. Why will the nurse position the client in bed with HOB elevated to 30 degrees?
- A. Makes it easier for the client to breathe
- B. Prevents the Valsalva maneuver
- C. Promotes venous drainage
- D. Reduces pain
Correct Answer: C
Rationale: Elevating the head of the bed to 30 degrees promotes venous drainage from the brain, reducing intracranial pressure (ICP). This position helps improve cerebral perfusion and prevents complications associated with increased ICP, such as brain herniation.