Nokea
When positioning the patient after a total hip arthroplasty with a posterior approach, it is important that the nurse maintain the affected extremity in what position?
- A. Adduction and flexion
- B. Abduction and extension
- C. Abduction and internal rotation
- D. Adduction and external rotation
Correct Answer: B
Rationale: Abduction and extension prevent dislocation.
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An elderly patient presents with a right-sided headache and acute loss of vision on the same side. Tenderness is noted to the right temporal region as well as to the scalp. To obtain a definitive diagnosis, the nurse practitioner will order:
- A. Erythrocyte sedimentation rate (ESR)
- B. C-reactive protein (CRP)
- C. Temporal artery biopsy
- D. CT scan of the head
Correct Answer: C
Rationale: The correct answer is C: Temporal artery biopsy. This is the gold standard for diagnosing giant cell arteritis, which presents with symptoms such as headache, vision loss, and tenderness to the temporal region and scalp. The biopsy will show characteristic inflammatory changes in the artery wall.
A: ESR and B: CRP are nonspecific markers of inflammation and can be elevated in various conditions, including giant cell arteritis, but they do not provide a definitive diagnosis.
D: CT scan of the head may show signs of inflammation in the temporal artery, but it is less sensitive than a biopsy for diagnosing giant cell arteritis.
The nurse instructs a client who has a neurological deficit regarding nutrition and diet. What should the client do?
- A. Eat two large meals instead of frequent small meals.
- B. Consume a diet low in fiber.
- C. Chew foods quickly.
- D. Be sure to take fluids frequently.
Correct Answer: D
Rationale: Staying hydrated is crucial for clients with neurological deficits to prevent constipation and urinary tract infections.
Meningeal sign is the following:
- A. Babinsky
- B. Kernig
- C. Lasseg
- D. Romberg
Correct Answer: B
Rationale: Kernig's sign is the correct answer because it is a clinical sign of meningeal irritation, often seen in meningitis. It is elicited by attempting to extend the knee while the hip is flexed, which causes pain and resistance due to inflammation of the meninges.
The nurse is caring for a client with ICP. Why will the nurse position the client in bed with HOB elevated to 30 degrees?
- A. Makes it easier for the client to breathe
- B. Prevents the Valsalva maneuver
- C. Promotes venous drainage
- D. Reduces pain
Correct Answer: C
Rationale: Elevating the head of the bed to 30 degrees promotes venous drainage from the brain, reducing intracranial pressure (ICP). This position helps improve cerebral perfusion and prevents complications associated with increased ICP, such as brain herniation.
Nervous System consists of:
- A. Brain
- B. Spinal Cord
- C. Nerves
- D. All the above
Correct Answer: D
Rationale: The nervous system is composed of the brain, spinal cord, and nerves, which work together to control and coordinate the body's activities. The brain processes information, the spinal cord transmits signals, and the nerves connect the central nervous system to the rest of the body, making 'All the above' the correct answer.