Nokea
When testing for motor function, the nurse should be aware of:
- A. Symmetry and strength of muscle movements.
- B. The patient's skin color and temperature.
- C. The patient's blood glucose levels.
- D. The patient's heart rate and rhythm.
Correct Answer: A
Rationale: Motor function testing involves assessing symmetry and strength of muscle movements. Skin color, blood glucose levels, and heart rate are unrelated to motor function.
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To plan effective care for patients diagnosed with somatic system disorders, the nurse should understand that patients have difficulty giving up the symptoms because the symptoms:
- A. are generally chronic in nature.
- B. have a physiological basis.
- C. can be voluntarily controlled.
- D. provide relief from health anxiety.
Correct Answer: D
Rationale: Step-by-step rationale:
1. Patients with somatic symptom disorders often experience health anxiety.
2. Symptoms provide a form of relief or distraction from this anxiety.
3. Understanding this helps nurses plan effective care by addressing underlying anxiety.
4. Option D is correct as it directly addresses the role of symptoms in providing relief.
Summary:
- Option A is incorrect because chronicity does not explain the reluctance to give up symptoms.
- Option B is incorrect as having a physiological basis does not necessarily relate to difficulty giving up symptoms.
- Option C is incorrect because symptoms in somatic system disorders are typically not voluntarily controlled.
The upper motor neuron impairment produces the following change of muscles tone:
- A. flaccidity
- B. spasticity
- C. "cog wheel" rigidity
- D. myoclonia
Correct Answer: B
Rationale: Spasticity is the correct answer because upper motor neuron lesions typically result in increased muscle tone due to the loss of inhibitory signals from the brain. This leads to hyperreflexia, clonus, and rigidity, which are hallmark signs of spasticity. The condition arises from damage to the corticospinal tract, which disrupts the balance of excitatory and inhibitory inputs to the motor neurons.
The presence of dysdiadochokinesis suggests damage to the following:
- A. black substance
- B. spinal cord
- C. cerebellar
- D. occipital lobe
Correct Answer: C
Rationale: Cerebellar is the correct answer because dysdiadochokinesis, or the inability to perform rapid alternating movements, is a hallmark sign of cerebellar dysfunction. The cerebellum is responsible for coordinating voluntary movements, and damage to this area disrupts the timing and precision of motor actions.
The dermatome supplying the great toe is usually
- A. L3
- B. L4
- C. L5
- D. S1
Correct Answer: C
Rationale: The L5 dermatome supplies the great toe and the dorsum of the foot. This is important in diagnosing lumbar nerve root compression.
A young adult client complains of blurred vision and muscle spasms that come and go over the past several months. On what information from the client's history should the nurse focus to help identify this help problem?
- A. Family history of Parkinson disease
- B. Family history of epilepsy
- C. Is an immigrant from Germany
- D. Has been depressed
Correct Answer: C
Rationale: A family history of MS or related autoimmune conditions, as well as geographic factors (e.g., higher prevalence in northern latitudes), can provide clues to the diagnosis. Depression is common in MS but is not diagnostic.