Nokea
Which intervention should you delegate to the nursing assistant for a patient with osteoporosis and risk for falls?
- A. Identify environmental factors that increase risk for falls.
- B. Monitor gait, balance, and fatigue level with ambulation.
- C. Collaborate with physical therapy to provide patient with walker.
- D. Assist the patient with ambulation to bathroom and in halls.
Correct Answer: D
Rationale: Assisting with ambulation is a task that can be safely delegated to a nursing assistant.
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For a patient with a one-sided spinal injury, the nurse must be careful about the temperature of the bath water because the patient's temperature sensation is lost
- A. contralaterally below the injury
- B. ipsilaterally below the injury
- C. bilaterally below the injury
- D. contralaterally above the injury
Correct Answer: A
Rationale: Temperature sensation is lost contralaterally below the injury level.
A patient diagnosed with somatic symptom disorder has been in treatment for 4 weeks. The patient says, Although I'm still having pain, I notice it less and am able to perform more activities. The nurse should evaluate the treatment plan as:
- A. unsuccessful.
- B. minimally successful.
- C. partially successful.
- D. totally achieved.
Correct Answer: C
Rationale: The correct answer is C: partially successful. This is because the patient is showing improvement in symptoms and functioning, indicating some progress in treatment effectiveness. It is not considered unsuccessful (A) as there is improvement noted. It is not minimally successful (B) as the patient is experiencing noticeable improvement in pain and activity levels. It is also not totally achieved (D) as the patient still has some pain despite improvement in functioning. Overall, option C best reflects the patient's progress at this stage of treatment.
An older adult woman is admitted to the emergency department after falling at home. The nurse cautions her not to put weight on the leg after finding what in the patient assessment?
- A. Inability to move the toes and ankle
- B. Edema of the thigh extending to the knee
- C. Internal rotation of the leg with groin pain
- D. Shortening and external rotation of the leg
Correct Answer: D
Rationale: Shortening and external rotation indicate a hip fracture.
Which of the following is not a side effect of dopamine agonists?
- A. Drowsiness
- B. Nausea
- C. Impulse control disorder
- D. Livedo reticularis
Correct Answer: D
Rationale: Livedo reticularis is not a side effect of dopamine agonists. Common side effects include drowsiness, nausea, and impulse control disorders.
Which of the following is not a typical clinical manifestation of multiple sclerosis (MS)?
- A. Double vision
- B. Sudden bursts of energy
- C. Weakness in the extremities
- D. Muscle tremors
Correct Answer: B
Rationale: Sudden bursts of energy are not associated with MS. Fatigue, weakness, and muscle tremors are common symptoms.