Nokea
Which technique does the nurse use to test the triceps reflex?
- A. Holds the knee in a slightly flexed position while he or she strokes the end of the foot with a dull object
- B. Hold the patient's relaxed forearm with the hand slightly pronated while striking the appropriate tendon with a reflex hammer
- C. Holds the patient's constricted arm with elbow flexed at a 90 degree angle, places a thumb over the elbow, and strikes the appropriate tendon
- D. Holds the patient's relaxed arm with elbow flexed at a 90 degree angle in one hand and strikes the appropriate tendon just above the elbow with either end of the reflex hammer
Correct Answer: D
Rationale: To test the triceps reflex, the nurse holds the patient's relaxed arm with the elbow flexed at a 90-degree angle and strikes the triceps tendon just above the elbow with a reflex hammer. This assesses the C7-C8 nerve roots.
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The area of the brain stem that plays a role in consciousness and the awake/sleep cycle is the:
- A. thalamus
- B. reticular activating system (RAS)
- C. pineal gland
- D. limbic system
Correct Answer: B
Rationale: The reticular activating system (RAS) in the brain stem regulates consciousness and the sleep-wake cycle. The thalamus, pineal gland, limbic system, and cerebellum have different functions. Therefore, B is the correct answer.
The presence of Parkinsonism suggests damage to the following:
- A. caudate nucleus
- B. black substance
- C. cerebellar
- D. frontal lobe
Correct Answer: B
Rationale: Black substance (substantia nigra) is the correct answer because Parkinsonism is characterized by the degeneration of dopaminergic neurons in the substantia nigra. This leads to the classic symptoms of tremor, bradykinesia, and rigidity due to the loss of dopamine in the basal ganglia, which regulates movement.
A patient diagnosed with a somatic symptom disorder has the nursing diagnosis: Interrupted family processes, related to patient's disabling symptoms as evidenced by the spouse and children assuming roles and tasks that previously belonged to patient. An appropriate outcome is that the patient will:
- A. assume roles and functions of the other family members.
- B. demonstrate a resumption of former roles and tasks.
- C. focus energy on problems occurring in the family.
- D. rely on family members to meet his or her personal needs.
Correct Answer: B
Rationale: The correct answer is B: demonstrate a resumption of former roles and tasks. This outcome implies that the patient will regain the ability to fulfill their own roles and tasks within the family, indicating improvement in the interrupted family processes. This aligns with the goal of promoting the patient's independence and reducing the burden on other family members.
Choice A is incorrect because having the patient assume roles and functions of other family members does not address the underlying issue of the patient's somatic symptom disorder and may lead to further dysfunction within the family.
Choice C is incorrect as it suggests the patient should focus on problems in the family, which may not directly address the interrupted family processes related to the patient's symptoms.
Choice D is incorrect as it promotes dependency on family members to meet the patient's personal needs, which does not encourage the patient to regain their former roles and tasks within the family.
Nurse Williams is conducting a seminar on dementia for the staff at the senior care facility. She emphasizes the importance of understanding the most prevalent causes of dementia in the elderly population. Which condition does Nurse Williams identify as the most common cause of dementia among elderly individuals?
- A. Amyotrophic lateral sclerosis
- B. Alzheimer's disease
- C. Multiple sclerosis
- D. Parkinson's disease
Correct Answer: B
Rationale: Alzheimer's disease is the most common cause of dementia in the elderly, characterized by progressive memory loss and cognitive decline.
A dermatome is
- A. ?
- B. separated from a discontinuous dermatome by an axial line
- C. ?
- D. ?
Correct Answer: B
Rationale: Dermatomes are regions of skin supplied by sensory fibers from a single spinal nerve. Axial lines separate dermatomes that are supplied by discontinuous spinal nerves.