Nokea
Which intervention should you delegate to the nursing assistant for a patient with carpal tunnel syndrome preparing for surgery?
- A. Initiate placement of a splint for immobilization during the day.
- B. Assess the patient's wrist and hand for discoloration and brittle nails.
- C. Assist the patient with daily self-care measures such as bathing and eating.
- D. Test the patient for painful tingling in the four digits of the hand.
Correct Answer: C
Rationale: Daily self-care assistance is a suitable task for a nursing assistant.
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While collecting data the nurse learns that a patient with a neurological illness has not had a sense of smell for several decades. Which part of the central nervous system should the nurse question as being damaged in this patient?
- A. Brainstem
- B. Occipital lobe
- C. Hypothalamus
- D. Temporal lobe
Correct Answer: D
Rationale: The olfactory nerve (cranial nerve I) originates in the temporal lobe, and damage to this area can result in anosmia (loss of smell). The brainstem, occipital lobe, and hypothalamus are not directly involved in the sense of smell. Assessing olfactory function can provide clues about neurological damage.
The lateral half of the ankle is supplied by which dermatome
- A. L3
- B. L4
- C. L5
- D. S1
Correct Answer: D
Rationale: The S1 dermatome supplies the lateral aspect of the ankle and foot. This is important in diagnosing sacral nerve root compression.
A patient with a spinal cord injury at level C3-4 is being cared for in the ED. What is the priority assessment?
- A. Determine the level at which the patient has intact sensation.
- B. Assess the level at which the patient has retained mobility.
- C. Check blood pressure and pulse for signs of spinal shock.
- D. Monitor respiratory effort and oxygen saturation level.
Correct Answer: D
Rationale: Respiratory function is critical at this level of injury and must be assessed immediately.
When assessing a patient for signs of increased intracranial pressure (ICP), the nurse should look for:
- A. Changes in level of consciousness, headache, and vomiting.
- B. Normal pupil size and reaction.
- C. Absence of nausea or vomiting.
- D. Clear and coordinated movements.
Correct Answer: A
Rationale: Increased intracranial pressure (ICP) is associated with changes in consciousness, headache, and vomiting. Normal pupil size, absence of nausea, and clear movements are not indicative of ICP.
A patient recovering from an acute exacerbation of RA tells the nurse that she is too tired to bathe. What should the nurse do for this patient?
- A. Give the patient a bed bath to conserve her energy.
- B. Allow the patient a rest period before showering with the nurse's help.
- C. Tell the patient that she can skip bathing if she will walk in the hall later.
- D. Inform the patient that it is important for her to maintain self-care activities.
Correct Answer: A
Rationale: Conserving energy is critical during flares.