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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The nurse notes that a patient is not able to voluntarily move the right arm. Which part of the brain should the nurse suspect is affected in this patient?
- A. Cerebellum
- B. Frontal lobe
- C. Parietal lobe
- D. Hypothalamus
Correct Answer: B
Rationale: The frontal lobes contain the motor areas that generate the impulses that bring about voluntary movement. Each motor area controls movement on the opposite side of the body. The cerebellum is responsible for coordination and balance, while the parietal lobe processes sensory information. The hypothalamus regulates autonomic functions and is not directly involved in voluntary movement.
Proper body alignment of the hemiplegic patient with the use of a footboard, trochanter rolls, and pillows will minimize the development of
- A. plantar extension
- B. shoulder abduction
- C. internal hip rotation
- D. external hip rotation
Correct Answer: A
Rationale: Footboards prevent plantar extension deformities.
A 63-year-old patient with PD has done well on rasagiline 1 mg once a day and ropinirole 4 mg three times a day for several years. In the past, higher doses of ropinirole resulted in excessive drowsiness. He now needs more symptom relief. The best recommendation would be to:
- A. Add carbidopa/levodopa.
- B. Add entacapone.
- C. Add pramipexole.
- D. Consider DBS surgery.
Correct Answer: A
Rationale: Adding carbidopa/levodopa can provide additional symptom relief without increasing the risk of drowsiness associated with higher doses of ropinirole.
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.
What should be included in the management of a patient with delirium?
- A. The use of restraints to protect the patient from injury
- B. The use of short-acting benzodiazepines to sedate the patient
- C. Identification and treatment of underlying causes when possible
- D. Administration of high doses of an antipsychotic drug such as haloperidol (Haldol)
Correct Answer: C
Rationale: Identifying and treating underlying causes is key in managing delirium.