Nokea
What should the nurse include in discharge instructions for the patient following a hip prosthesis with a posterior approach?
- A. Restrict walking for 2 to 3 months.
- B. Take a bath rather than a shower to prevent falling.
- C. Keep the leg internally rotated while sitting and standing.
- D. Have a family member put on the patient's shoes and socks.
Correct Answer: D
Rationale: Family assistance minimizes strain on the hip.
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A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that suddenly started a short time ago. Assessment of the patient reveals increased blood pressure (168/94) and decreased heart rate (48/minute), diaphoreses, and flushing of the face and neck. What action should you take first?
- A. Administer the ordered acetaminophen (Tylenol).
- B. Check the Foley tubing for kinks or obstruction.
- C. Adjust the temperature in the patient's room.
- D. Notify the physician about the change in status.
Correct Answer: B
Rationale: Checking the Foley tubing is critical as it could indicate autonomic dysreflexia, a life-threatening condition in SCI patients.
In assessing Bob, which of the following complaints would indicate radial nerve injury?
- A. Pain at the fracture site
- B. Inability to extend the wrist
- C. Inability to flex the elbow
- D. Paralysis of the hand and forearm
Correct Answer: B
Rationale: The radial nerve primarily controls wrist extension; inability to extend the wrist indicates radial nerve damage.
The nurse recognizes what as the major problem in the management of RA in the older adult?
- A. RA is usually more severe in older adults.
- B. Older patients are not as likely to comply with treatment regimens.
- C. Drug interactions and toxicity are more likely to occur with multidrug therapy.
- D. Laboratory and other diagnostic tests are not effective in identifying RA in older adults.
Correct Answer: C
Rationale: Polypharmacy increases risks in older adults.
When an individual displays a deficit in the comprehension of speech involving difficulties in recognising spoken words and converting thoughts into words is known as
- A. Wernicke's aphasia
- B. Broca's aphasia
- C. Beidecker's aphasia
- D. Warnick's aphasia
Correct Answer: A
Rationale: Wernicke's aphasia is a language disorder characterized by difficulties in understanding spoken language and converting thoughts into coherent speech. Individuals with this condition may produce fluent but nonsensical speech and struggle to recognize spoken words. This condition results from damage to Wernicke's area, a region in the temporal lobe responsible for language comprehension.
Which of the following signs is present in a client with meningitis and is described as the inability to extend the leg when the thigh is flexed on the abdomen?
- A. Opisthotonos
- B. Positive Brudzinski's sign
- C. Positive Kernig's sign
- D. Nuchal rigidity
Correct Answer: C
Rationale: Kernig's sign is characterized by this specific limitation in leg extension.