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Which factor is the nurse aware of when assessing a person with a craniocerebral injury?
- A. Most injuries of this type are irreversible.
- B. Open injuries are always more serious than closed injuries.
- C. Signs and symptoms may not occur until several days after the trauma.
- D. Trauma to the frontal lobe is more significant than to any other area.
Correct Answer: C
Rationale: If a patient who has been conscious for several days after head injury loses consciousness or develops neurologic signs and symptoms, a subdural hematoma should be suspected.
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Which Glasgow Coma Scale rating would a patient receive who opens the eyes spontaneously, but has incomprehensible speech and obeys commands for movement?
- A. 8
- B. 10
- C. 11
- D. 12
Correct Answer: D
Rationale: The Glasgow Coma Scale was developed in 1974, and it consists of three parts of the neurologic assessment: eye opening, best motor response, and best verbal response. This patient gets a 4 for eye opening, a 2 for incomprehensible speech, and a 6 for moving on demand.
The newly admitted patient to the emergency room 30 minutes ago after a fall off a ladder has gradually decreased in consciousness and has slowly reacting pupils, a widening pulse pressure, and verbal responses that are slow and unintelligible. Which position is most appropriate for the patient?
- A. Neck placed in a neutral position.
- B. Head raised slightly with hips flexed.
- C. Supine in gravity neutral position.
- D. Turn on right side with head elevated.
Correct Answer: A
Rationale: The patient is experiencing increased intracranial pressure. To assist with reducing the intracranial pressure, place the patient's neck in a neutral position (not flexed or extended) to promote venous drainage.
The nurse is caring for a patient who had a spinal cord injury at C5 3 years ago. The nurse expects the plan of care will focus on the knowledge that the patient will be able to do which activity independently?
- A. feed self with setup and adaptive equipment.
- B. transfer self to wheelchair.
- C. stand erect with full leg braces.
- D. sit with good balance.
Correct Answer: A
Rationale: A cord injury at C5 allows for ability to drive an electric wheelchair with mobile hand supports and feed self with adaptive equipment.
A patient is in which stage of Alzheimer's disease when demonstrating difficulty swallowing?
- A. Pre-Alzheimer's
- B. Early
- C. Middle
- D. Late
Correct Answer: D
Rationale: The patient who demonstrates difficulty swallowing is in the late, or severe, stage.
Which sign is the first sign of Bell's palsy?
- A. Inability to wrinkle forehead and pucker lips on affected side
- B. Sudden pain in nostril on affected side
- C. Excessive salivation on the affected side
- D. Excessive mucus running from nostril on affected side
Correct Answer: A
Rationale: Unilateral weakness of the facial muscles usually occurs, resulting in a flaccidity of the affected side of the face with inability to wrinkle the forehead, close the eyelid, pucker the lips, smile, frown, whistle, or retract the mouth on that side. The face appears asymmetric.