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What test provides fast, precise measurement of the bone mass of the spine, forearm, and total body to evaluate osteoporosis?
- A. Bone scan
- B. Diskogram
- C. Quantitative ultrasound (QUS)
- D. Dual energy x-ray absorptiometry (DXA)
Correct Answer: D
Rationale: DXA is the gold standard for bone density measurement.
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What is a normal response when testing cranial nerve IX (Glossopharyngeal nerve) and X (Vagus nerve)?
- A. The uvula should remain midline when the patient says "ah."
- B. The patient should be able to smell different scents.
- C. The patient should have normal hearing.
- D. The patient should exhibit symmetrical facial expressions.
Correct Answer: A
Rationale: Cranial nerves IX and X are tested by observing the uvula's position when the patient says "ah." A midline uvula indicates normal function. Smell, hearing, and facial expressions are assessed by other cranial nerves.
A patient says, I feel detached and weird all the time, like I'm looking at life through a cloudy window. Everything seems unreal. These feelings really interfere with my work and study. Which term should the nurse use to document this complaint?
- A. Depersonalization
- B. Hypochondriasis
- C. Dissociation
- D. Malingering
Correct Answer: A
Rationale: Correct Answer: A. Depersonalization
Rationale:
1. Depersonalization involves feeling detached from oneself or reality, as described by the patient.
2. The patient's description of feeling like they are looking through a cloudy window aligns with depersonalization symptoms.
3. Interference with work and study suggests significant distress, a common feature of depersonalization disorder.
Summary of other choices:
B. Hypochondriasis: Involves excessive worry about having a serious illness, which is not indicated in the patient's complaint.
C. Dissociation: While depersonalization is a type of dissociative symptom, it specifically refers to feeling detached and unreal, not necessarily a broader dissociative disorder.
D. Malingering: Involves feigning or exaggerating symptoms for secondary gain, which is not evident in the patient's genuine distress and impairment.
In the acute phase following a cerebrovascular accident, patients have a tendency to develop pressure lesions for all of the following reasons EXCEPT
- A. high degree of muscle spasticity
- B. accompanying sensory loss
- C. interference with altered autonomic reflexes
- D. diminished muscle use
Correct Answer: A
Rationale: Spasticity does not typically contribute to pressure ulcers.
Which of the following is an incorrect pairing?
- A. norepinephrine dilates the pupil
- B. epinephrine increases blood pressure
- C. acetylcholine decreases digestion
- D. norepinephrine increases heart rate
Correct Answer: C
Rationale: The correct answer is C because acetylcholine actually increases digestion by stimulating the release of digestive enzymes and promoting peristalsis. A is incorrect because norepinephrine dilates the pupil, B is incorrect because epinephrine does increase blood pressure, and D is incorrect because norepinephrine does increase heart rate. Remember, acetylcholine is primarily responsible for parasympathetic responses, which include rest and digest functions.
Which assessment finding may indicate a stroke?
- A. Sudden weakness on one side of the body, difficulty speaking, or confusion.
- B. Steady gait and normal muscle strength.
- C. Clear, intact sensation in all extremities.
- D. Symmetrical deep tendon reflexes.
Correct Answer: A
Rationale: Sudden weakness, difficulty speaking, or confusion are hallmark signs of a stroke. Steady gait, intact sensation, and symmetrical reflexes are normal findings.