Nokea
Which of the following nursing diagnoses pertains to a client with a neurological deficit in relation to his marriage?
- A. Risk for Disuse Syndrome related to musculoskeletal inactivity and neuromuscular impairment
- B. Total Urinary Incontinence or Urinary Retention related to effects of disease or injury to the nervous system or spinal cord nerves
- C. loss of bladder tone
- D. Impaired Physical Mobility related to muscle weakness and paralysis
Correct Answer: D
Rationale: Neurological deficits can affect sexual function, impacting relationships.
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An increase in PaCO2 leads to:
- A. hypertension
- B. increased adrenaline release
- C. increased sweating
- D. all above
Correct Answer: D
Rationale: Increased PaCO2 (hypercapnia) causes hypertension, adrenaline release, and sweating due to activation of the sympathetic nervous system. These responses aim to restore normal CO2 levels.
What is another name for the preganglionic sympathetic fibers that project to the heart?
- A. solitary tract
- B. vasomotor nerve
- C. vagus nerve
- D. cardiac accelerator nerve
Correct Answer: D
Rationale: The correct answer is D: cardiac accelerator nerve. Preganglionic sympathetic fibers that project to the heart are part of the cardiac accelerator nerves, which increase heart rate and force of contraction. The other choices are incorrect because:
A: solitary tract - involved in transmitting sensory information related to taste and visceral sensations.
B: vasomotor nerve - regulates blood vessel tone and blood pressure.
C: vagus nerve - part of the parasympathetic nervous system and slows down heart rate and decreases force of contraction.
When obtaining information about the patient's use of medications, the nurse recognizes that both bone and muscle function may be impaired when the patient reports taking what type of drug?
- A. Corticosteroids
- B. Oral hypoglycemic agents
- C. Potassium-depleting diuretics
- D. Nonsteroidal antiinflammatory drugs (NSAIDs)
Correct Answer: A
Rationale: Corticosteroids weaken bones and muscles.
Dysphasia suggests the impairment of:
- A. speech
- B. gait
- C. swallowing
- D. movement
Correct Answer: A
Rationale: Speech is the correct answer because dysphasia refers to a language disorder that affects the ability to produce or comprehend spoken or written language. It is typically caused by damage to the language centers of the brain, such as Broca's or Wernicke's areas, and results in difficulties with communication.
Which of the following factors should the nurse emphasize while teaching a client with a cast on the lower extremities?
- A. The importance of following a regular diet.
- B. The use of prescribed analgesics to manage the pain.
- C. Instructions about ambulating with the crutches.
- D. The importance of regular exercise.
Correct Answer: C
Rationale: Ambulation instructions are critical to ensure safe movement with casts.