Nokea
When assessing a patient's response to stimuli, the nurse should:
- A. Observe for changes in the patient's reaction to verbal and physical stimuli.
- B. Measure the patient's heart rate.
- C. Inspect the patient's skin for lesions.
- D. Check the patient's blood pressure.
Correct Answer: A
Rationale: Response to stimuli is assessed by observing the patient's reaction to verbal and physical stimuli. Heart rate, skin lesions, and blood pressure are unrelated to this assessment.
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A 30-year-old female presents with muscle weakness in the lower extremities and palpitations. Her symptoms have been progressively worse over the course of a 2 weeks. She reports to be in great health, but had a period of abdominal pain and diarrhea approximately 5 weeks ago. Her temperature is 98.9 deg F (37.2 deg C), blood pressure 117/82 mmHg, pulse is 102/min, and respirations are 16/min. On physical exam, there is 4-/5 muscle strength throughout the lower extremities. Bilateral patellar reflexes are 1+ and ankle reflexes are absent. Lumbar puncture was performed, and results are pending. Part 2: What is the most appropriate initial treatment?
- A. High dose corticosteroids
- B. Intravenous immunoglobulin
- C. Potassium chloride
- D. Pyridostigmine
Correct Answer: B
Rationale: Intravenous immunoglobulin (IVIG) is the first-line treatment for Guillain-Barre syndrome (GBS). It works by modulating the immune response and reducing the severity of the disease. High-dose corticosteroids are not effective in GBS, and potassium chloride and pyridostigmine are not indicated for this condition.
The nurse is providing care for an 87-year-old woman who is recovering from a cerebral vascular accident. Which precaution should the nurse take after noting the patient has a positive Romberg test?
- A. Institute fall-risk precautions.
- B. Provide small, frequent meals.
- C. Request a footboard and splints.
- D. Darken the room and reduce stimuli.
Correct Answer: A
Rationale: A positive Romberg test indicates impaired balance and proprioception, increasing the risk of falls. Fall-risk precautions, such as using a gait belt and ensuring a safe environment, are essential. Small meals, footboards, and reducing stimuli are not directly related to balance issues.
Babinsky response usually develops with damage in:
- A. upper motor neuron
- B. lower motor neuron
- C. cerebellar
- D. thalamus
Correct Answer: A
Rationale: Upper motor neuron is the correct answer because the Babinski sign is a pathological reflex indicative of damage to the corticospinal tract. It is characterized by the extension of the big toe and fanning of the other toes upon stimulation of the sole, which is abnormal in adults and suggests a loss of inhibitory control from the brain.
Which motor symptom, visible in the hands, is characteristic of Parkinson's disease?
- A. blue discoloration
- B. red discoloration
- C. tremor
- D. severe edema
Correct Answer: C
Rationale: Tremor, particularly a resting tremor, is a hallmark symptom of Parkinson's disease. It often begins in the hands and can progress to other parts of the body as the disease advances.
Which intervention should the nurse delegate to the licensed practical nurse (LPN) when caring for a patient following an acute stroke?
- A. Assess the patient's neurologic status.
- B. Assess the patient's gag reflex before beginning feeding.
- C. Administer ordered antihypertensives and platelet inhibitors.
- D. Teach the patient's caregivers strategies to minimize unilateral neglect.
Correct Answer: C
Rationale: Administering medications is typically within the scope of practice for LPNs