Nokea
Which assessment finding best supports the diagnosis of dissociative amnesia with fugue? The patient states:
- A. I cannot recall why I'm living in this town.
- B. I feel as if I'm living in a fuzzy dream state.
- C. I feel like different parts of my body are at war.
- D. I feel very anxious and worried about my problems.
Correct Answer: A
Rationale: The correct answer is A because the key feature of dissociative amnesia with fugue is the inability to remember important personal information. In this case, the patient cannot recall why they are living in the current town, indicating a significant gap in memory. Choice B describes a feeling of disorientation, not memory loss. Choice C suggests dissociative identity disorder, not dissociative amnesia. Choice D focuses on anxiety, which is not a primary symptom of dissociative amnesia with fugue.
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An important nursing intervention for the patient with ankylosing spondylitis is to teach the patient to do what?
- A. Wear roomy shoes with good orthotic support.
- B. Sleep on the side with the knees and hips flexed.
- C. Keep the spine slightly flexed while sitting, standing, or walking.
- D. Perform back, neck, and chest stretches and deep-breathing exercises.
Correct Answer: D
Rationale: Stretching exercises maintain flexibility.
Nurse Parker is overseeing the care of a patient with Parkinson's disease who has been consistently taking carbidopa/levodopa (Sinemet) for a year. She is attentively monitoring for any potential adverse reactions associated with this specific medication. Which adverse reaction should Nurse Parker be particularly vigilant about in monitoring this patient?
- A. The occurrence of dyskinesia.
- B. The emergence of respiratory depression.
- C. The onset of glaucoma.
- D. The development of a rash or other signs of an allergic reaction.
Correct Answer: A
Rationale: Dyskinesia, or involuntary movements, is a common adverse reaction to long-term levodopa therapy in PD patients.
Anti-diuretic hormone (ADH):
- A. is synthesized by the posterior lobe of the pituitary gland
- B. is released by neurosecretion
- C. its secretion is increased by a low plasma osmolarity
- D. increases the permeability of the distal convoluted tubule
Correct Answer: B
Rationale: ADH is synthesized in the hypothalamus and released by the posterior pituitary via neurosecretion. Its secretion is increased by high plasma osmolarity or low blood volume. ADH increases water reabsorption in the distal convoluted tubule and collecting ducts by increasing their permeability to water.
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.
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.