Nokea
When assessing the patient, you notice that there is contraction of his facial muscle after tapping the facial nerve anterior to his ear. This is a sign of
- A. Hyponatremia.
- B. Hypokalemia.
- C. Hypomagnesemia.
- D. Hypocalcemia.
Correct Answer: D
Rationale: Facial twitching upon tapping the facial nerve is a sign of hypocalcemia.
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Identify what short-term evaluation technique is appropriate to assess whether the patient has met the following learning goals.
- A. Demonstration
- B. Verbalization
- C. Selection
- D. Observation
Correct Answer: B
Rationale: Each learning goal requires a different evaluation technique: Demonstration for subcutaneous insulin injection, Verbalization for identifying side effects of Coumadin, Selection for choosing potassium-rich foods, Observation for verbalizing no shortness of breath, and Verbalization for stating readiness to change a dressing. The correct technique depends on the specific goal.
A client with end-stage heart failure who is awaiting a transplant appears depressed and states, 'I know a transplant is my last chance, but I don't want to become a vegetable.' How should the nurse respond?
- A. Would you like information about advance directives?
- B. I will arrange for a psychiatrist to speak with you.
- C. Do you want to come off the transplant list?
- D. Would you like to speak with a priest or chaplain?
Correct Answer: A
Rationale: The correct answer is A: Would you like information about advance directives? This is the appropriate response as it addresses the client's concerns about becoming a vegetable and explores their wishes for end-of-life care. Advance directives can help the client make decisions about their care in case they are unable to communicate in the future. The other choices are incorrect because B assumes the client needs psychiatric evaluation, C suggests removing them from the transplant list without exploring their concerns further, and D focuses on spiritual support rather than addressing the client's specific worries about their quality of life post-transplant.
What is the definition of blindness in terms of the best corrected visual acuity (BCVA)?
- A. Less than 20/200 even with correction
- B. Between 20/70 and 20/200 in the better eye with glasses
- C. 20/400 or greater with no light perception
- D. 20/40 in at least one eye with correction
Correct Answer: A
Rationale: Blindness is legally defined as BCVA less than 20/200 in the better eye with correction.
Once generated, what may block the transmission of an action potential along a peripheral nerve fiber to the dorsal root of the spinal cord?
- A. The transmission may be interrupted by drugs such as local anesthetics.
- B. Nothing can stop the action potential along an intact nerve until it reaches the spinal cord.
- C. The action potential must cross several synapses, points at which the impulse may be blocked by drugs.
- D. The nerve fiber produces neurotransmitters that may activate nearby nerve fibers to transmit pain impulses.
Correct Answer: A
Rationale: The correct answer is A. Local anesthetics can block the transmission of action potentials along peripheral nerves.
When teaching a client with chronic obstructive pulmonary disease about oxygen by cannula, the nurse should also instruct the client's family to:
- A. Avoid smoking near the client.
- B. Turn off oxygen during meals.
- C. Adjust the liter flow to 10 as needed.
- D. Remind the client to keep mouth closed.
Correct Answer: A
Rationale: Smoking near oxygen poses a fire hazard and exacerbates respiratory issues.