Nokea
Which is a sign of Cushing response?
- A. Increased pulse rate
- B. Increased blood pressure
- C. Widened pulse pressure
- D. Bradycardia
- E. Increased systolic blood pressure
- F. Uncontrolled thermoregulation
Correct Answer: C,D,E
Rationale: A widened pulse pressure, increased systolic blood pressure, and bradycardia are together called Cushing response. It is considered an important diagnostic sign of late-stage brain herniation.
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Which symptom is specific to migraine headaches?
- A. Tachycardia
- B. They become worse in the evening
- C. They involve the entire head
- D. They are preceded by an aura
Correct Answer: D
Rationale: Migraine headaches are unusual in that signs and symptoms occur before the acute attack.
Which cranial nerve supplies most of the organs in the thoracic and abdominal cavities and carries motor fibers to glands that produce digestive juices and other secretions?
- A. Somatic motor nerve
- B. Visceral sensory nerve
- C. Abducens nerve
- D. Vagus nerve
Correct Answer: D
Rationale: The vagus nerve extends from the throat, larynx, and organs in the thoracic and abdominal cavities. It is responsible for sensations and will accelerate peristalsis when stimulated.
As the result of a stroke, a patient has difficulty discerning the position of his body without looking at it. In the nurse's documentation, which term would best describe the patient's inability to assess spatial position of his body?
- A. Agnosia
- B. Loss of proprioception
- C. Apraxia
- D. Sensation
Correct Answer: B
Rationale: Patients may experience a loss of proprioception with a stroke. This may include apraxia and agnosia (a total or partial loss of the ability to recognize familiar objects or people).
A ___ is a diagnostic procedure used to identify lesions by observing the flow of radiopaque dye through the subarachnoid space.
Correct Answer: myelogram
Rationale: Preparation for this procedure is the same as for lumbar puncture.
Which technique is necessary for safely feeding a patient with hemiplegia?
- A. Mixing liquids and solid foods together
- B. Taking the patient's dentures out to prevent choking
- C. Checking the affected side of mouth for food accumulation
- D. Offering small bites of food
- E. Elevating the patient to no more than 30 degrees
- F. Adding a thickening agent to liquids
Correct Answer: C,D,F
Rationale: Important nursing measures include avoiding foods that cause choking, checking the affected side of the mouth for accumulation of food and resultant poor hygiene, not mixing liquids and solid foods, and encouraging the patient to take small bites.