Nokea
When planning range-of-motion exercises with Mrs. Iris, which exercises for the right leg would it be important for her to perform?
- A. Adduction of the leg
- B. 45° knee flexion and extension exercises
- C. Gluteal muscle-setting exercises
- D. Dorsiflexion and plantar flexion of the foot
Correct Answer: C
Rationale: Gluteal muscle exercises strengthen muscles supporting the hip joint.
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When utilizing the Glasgow Coma Scale, the nurse knows coma will be represented by a score of
- B. 2
- C. 6 (8 or less indicates coma)
- D. 10
Correct Answer: C
Rationale: A Glasgow Coma Scale (GCS) score of 8 or less indicates coma. The GCS assesses eye, verbal, and motor responses to determine the level of consciousness. Lower scores reflect more severe neurological impairment, with a score of 3 indicating deep coma or brain death.
To assess the Glasgow Coma Scale (GCS), the nurse needs to evaluate:
- A. Eye opening, verbal response, and motor response.
- B. Heart rate, blood pressure, and temperature.
- C. Pupil size, reaction to light, and accommodation.
- D. Skin turgor, moisture, and temperature.
Correct Answer: A
Rationale: The Glasgow Coma Scale (GCS) assesses a patient's level of consciousness based on eye opening, verbal response, and motor response. It is a standardized tool used in neurological assessments.
In discharge planning with Mrs. Post, it will be important to teach her to avoid exposure to the sun because
- A. concurrent use of steroids and sun exposure lessens the drug's effectiveness
- B. sunlight may cause ulceration of skin lesions
- C. sunlight may aggravate rash and arthritis
- D. the skin will be more sensitive to burning
Correct Answer: C
Rationale: Sunlight exposure can worsen lupus symptoms.
Which of the following might indicate a problem with the patient's sensory system?
- A. Inability to feel light touch or pain in specific areas.
- B. Normal sensation throughout the body.
- C. Clear and accurate perception of temperature.
- D. Absence of tingling or numbness.
Correct Answer: A
Rationale: Inability to feel light touch or pain suggests sensory system dysfunction. Normal sensation, accurate temperature perception, and absence of tingling are expected findings.
The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to the nursing assistant?
- A. Document the seizure.
- B. Perform neurologic checks.
- C. Take the patient's vital signs.
- D. Restrain the patient for protection.
Correct Answer: C
Rationale: Taking vital signs is a routine task that can be delegated to a nursing assistant while documenting seizures and performing neurologic checks require more specialized knowledge.