Nokea
What would be an abnormal finding when assessing cranial nerve III (Oculomotor nerve)?
- A. Pupil dilation or asymmetry.
- B. Constricted pupils.
- C. Equal and reactive pupils.
- D. Normal eye movement.
Correct Answer: A
Rationale: Pupil dilation or asymmetry indicates dysfunction of cranial nerve III (Oculomotor nerve). Constricted pupils, equal and reactive pupils, and normal eye movement are normal findings.
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The following are found in higher concentration in the tear than in the serum:
- A. sodium
- B. potassium
- C. Ig G
- D. glucose
Correct Answer: B
Rationale: Tears have a higher concentration of potassium compared to serum. This is due to the active secretion of potassium ions by the lacrimal gland. Sodium, IgG, and glucose are typically found in lower concentrations in tears compared to serum.
Which action requires intervention by the charge nurse for an LPN/LVN caring for a patient with Paget's disease?
- A. Administers 600 mg of ibuprofen to the patient.
- B. Encourages the patient to perform PT recommended exercises.
- C. Applies ice and gentle massage to the patient's lower extremities.
- D. Reminds the patient to drink milk and eat cottage cheese.
Correct Answer: C
Rationale: Applying ice and massage without specific instructions may not be appropriate and could potentially cause harm.
What is the priority intervention in the emergency department for the patient with a stroke?
- A. Intravenous fluid replacement
- B. Administration of osmotic diuretics to reduce cerebral edema
- C. Initiation of hypothermia to decrease the oxygen needs of the brain
- D. Maintenance of respiratory function with a patent airway and oxygen administration
Correct Answer: D
Rationale: Maintaining a patent airway and oxygenation is critical in the initial management of stroke
Select the correct etiology to complete this nursing diagnosis for a patient diagnosed with dissociative identity disorder: Disturbed personal identity, related to:
- A. obsessive fears of harming self or others.
- B. poor impulse control and lack of self-confidence.
- C. depressed mood secondary to nightmares and intrusive thoughts.
- D. cognitive distortions associated with unresolved childhood abuse issues.
Correct Answer: D
Rationale: The correct answer is D because dissociative identity disorder (DID) is often linked to unresolved childhood abuse issues, leading to fragmentation of identity as a coping mechanism. This is supported by research showing a high prevalence of childhood trauma among individuals with DID. Option A is incorrect because it relates more to anxiety disorders. Option B is incorrect as it describes traits more associated with personality disorders. Option C is incorrect as it pertains to mood disorders like depression, which are not the primary etiology of DID.
The nurse suspects that a patient will be diagnosed as being in a comatose state based upon the Glasgow Coma Scale score. What score does the patient need to have to be identified as comatose?
- A. 7
- B. 9
- C. 11
- D. 13
Correct Answer: A
Rationale: A GCS score of 7 or less indicates a comatose state, while a score of 15 indicates full alertness. Scores of 9, 11, and 13 suggest varying degrees of neurological impairment but not coma. Recognizing a comatose state is critical for patient management.