Nokea
When assessing a patient for signs of increased intracranial pressure (ICP), the nurse should look for:
- A. Changes in level of consciousness, headache, and vomiting.
- B. Normal pupil size and reaction.
- C. Absence of nausea or vomiting.
- D. Clear and coordinated movements.
Correct Answer: A
Rationale: Increased intracranial pressure (ICP) is associated with changes in consciousness, headache, and vomiting. Normal pupil size, absence of nausea, and clear movements are not indicative of ICP.
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A patient is discharged from the outpatient clinic following application of a synthetic fiberglass long arm cast for a fractured ulna. Before discharge, the nurse instructs the patient to do what?
- A. Never get the cast wet.
- B. Move the shoulder and fingers frequently.
- C. Place tape petals around the edges of the cast when it is dry.
- D. Use a sling to support the arm at waist level for the first 48 hours.
Correct Answer: B
Rationale: Moving the unaffected parts promotes circulation and reduces stiffness.
A 28-year-old female patient has been diagnosed with occipital lobe damage after a car accident. What should the nurse expect the patient to need help with?
- A. Being able to feel heat
- B. Processing visual images
- C. Identifying smells appropriately
- D. Being able to say what she means
Correct Answer: B
Rationale: The occipital lobe is primarily responsible for processing visual images.
Priority Decision: A patient is admitted to the emergency department with a possible cervical spinal cord injury following an automobile crash. During admission of the patient, what is the highest priority for the nurse?
- A. Maintaining a patent airway
- B. Maintaining immobilization of the cervical spine
- C. Assessing the patient for head and other injuries
- D. Assessing the patient's motor and sensory function
Correct Answer: B
Rationale: Immobilization prevents further injury.
The brain is protected by:
- A. the meninges.
- B. a cushion of fluid.
- C. the bony skull.
- D. All of the above.
Correct Answer: D
Rationale: The brain is protected by multiple layers of defense, including the meninges (protective membranes), cerebrospinal fluid (a cushioning fluid), and the bony skull. The meninges consist of three layersâ€â€dura mater, arachnoid mater, and pia materâ€â€that provide structural support and protection. Cerebrospinal fluid surrounds the brain and spinal cord, acting as a shock absorber. The skull provides a rigid barrier against physical injury. Together, these structures safeguard the brain from damage.
Which of the following is not a realistic outcome to establish with a client who has multiple sclerosis (MS)? The client will develop:
- A. Joint mobility
- B. Muscle strength
- C. Cognition
- D. Mood elevation
Correct Answer: B
Rationale: While joint mobility, cognition, and mood elevation can be improved or maintained, muscle strength is often progressively affected by MS and may not be fully restored.