Nokea
Which of the following findings is common in clients with Paget's disease?
- A. Elevated serum alkaline phosphatase level
- B. Decreased urinary hydroxyproline excretion
- C. Elevated leukocyte count
- D. Elevated creatinine level
Correct Answer: A
Rationale: Elevated serum alkaline phosphatase is a marker of increased bone turnover in Paget's disease.
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The nurse needs to detect the presence of ischemia in a client with tissue injury. Which of the following signs and symptoms may indicate the presence of ischemia?
- A. Signs of fatigue
- B. Signs of respiratory depression
- C. Absence of a peripheral pulse
- D. Heavy swelling in the injured area
Correct Answer: C
Rationale: Ischemia often results in the absence of a peripheral pulse due to restricted blood flow.
Nurse Peterson is reviewing her notes on various neurological conditions to prepare for an upcoming training session. She focuses on a chronic, degenerative, progressive disease of the central nervous system, notable for small patches of demyelination in the brain and spinal cord. Which disease is Nurse Peterson studying?
- A. Huntington's disease
- B. Parkinson's disease
- C. Creutzfeldt-Jakob's disease
- D. Multiple sclerosis
Correct Answer: D
Rationale: Multiple sclerosis is characterized by demyelination in the central nervous system, leading to a variety of neurological symptoms.
The following conditions can affect the pupil size:
- A. iris colour
- B. fatigue
- C. exercise
- D. all above
Correct Answer: D
Rationale: Pupil size is influenced by factors such as iris color (darker irises may have smaller pupils), fatigue (pupils constrict with tiredness), and exercise (pupils dilate during physical activity). These changes are mediated by the autonomic nervous system.
A patient has blindness related to a functional neurological (conversion) disorder but is unconcerned about this problem. Which understanding should guide the nurse's planning for this patient? The patient is:
- A. suppressing accurate feelings regarding the problem.
- B. relieving anxiety through the physical symptom.
- C. meeting needs through hospitalization.
- D. refusing to disclose genuine fears.
Correct Answer: B
Rationale: The correct answer is B because the patient is unconcerned about the blindness, indicating that the symptom is relieving anxiety. This is characteristic of conversion disorder where physical symptoms alleviate psychological distress. Other choices are incorrect because the patient is not necessarily suppressing feelings (A), not meeting needs through hospitalization (C), and not refusing to disclose fears (D).
A 26 year-old man was in a motor vehicle accident and suffered a complete spinal cord injury to L3. The nurse assesses the patient for loss of motor function in the:
- A. Legs
- B. Abdomen
- C. Chest
- D. Arms
Correct Answer: A
Rationale: A spinal cord injury at the L3 level affects motor function in the legs. The abdomen, chest, and arms are controlled by higher spinal cord levels (thoracic and cervical). Loss of motor function in the legs is consistent with an L3 injury.