Nokea
Which type of seizure is most likely to cause death for the patient?
- A. Subclinical seizures
- B. Myoclonic seizures
- C. Psychogenic seizures
- D. Tonic-clonic status epilepticus
Correct Answer: D
Rationale: Status epilepticus is a life-threatening condition requiring immediate intervention
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What test provides fast, precise measurement of the bone mass of the spine, forearm, and total body to evaluate osteoporosis?
- A. Bone scan
- B. Diskogram
- C. Quantitative ultrasound (QUS)
- D. Dual energy x-ray absorptiometry (DXA)
Correct Answer: D
Rationale: DXA is the gold standard for bone density measurement.
A patient says, I feel detached and weird all the time, like I'm looking at life through a cloudy window. Everything seems unreal. These feelings really interfere with my work and study. Which term should the nurse use to document this complaint?
- A. Depersonalization
- B. Hypochondriasis
- C. Dissociation
- D. Malingering
Correct Answer: A
Rationale: Correct Answer: A. Depersonalization
Rationale:
1. Depersonalization involves feeling detached from oneself or reality, as described by the patient.
2. The patient's description of feeling like they are looking through a cloudy window aligns with depersonalization symptoms.
3. Interference with work and study suggests significant distress, a common feature of depersonalization disorder.
Summary of other choices:
B. Hypochondriasis: Involves excessive worry about having a serious illness, which is not indicated in the patient's complaint.
C. Dissociation: While depersonalization is a type of dissociative symptom, it specifically refers to feeling detached and unreal, not necessarily a broader dissociative disorder.
D. Malingering: Involves feigning or exaggerating symptoms for secondary gain, which is not evident in the patient's genuine distress and impairment.
A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient's deep tendon reflexes?
- A. Reflexes will be normal.
- B. Reflexes cannot be elicited.
- C. All reflexes will be diminished but present.
- D. Some reflexes will be present, depending on the area of injury.
Correct Answer: A
Rationale: The correct answer is A: Reflexes will be normal. In a patient with a head injury resulting from trauma and no other injuries, deep tendon reflexes are typically unaffected by the injury. The brain stem controls deep tendon reflexes, and since there are no other injuries, the reflexes should remain normal. Choices B, C, and D are incorrect because they do not align with the typical response of deep tendon reflexes in a head injury without other injuries. Choice B stating that reflexes cannot be elicited is incorrect as deep tendon reflexes are usually intact in this scenario. Choice C suggesting all reflexes will be diminished but present is incorrect as deep tendon reflexes are typically not affected by head injuries. Choice D stating that some reflexes will be present depending on the area of injury is incorrect because deep tendon reflexes are primarily controlled by the brain stem, which is not directly affected in this situation.
The wife of a patient who has a ruptured aneurysm asks how this could have happened considering that he passed a physical 3 months ago. What is the best response?
- A. Aneurysms are often asymptomatic.
- B. The physician must have misread the x-ray.
- C. The aneurysm must have developed since his physical.
- D. Do not be too concerned because this happens all the time.
Correct Answer: A
Rationale: Aneurysms can develop over time and may not show symptoms until they rupture.
Mrs. Aster occasionally has pain and stiffness in her hand and fingers. Which of the following nursing measures would most effectively ease her discomfort?
- A. Wrapping her hands in a heating pad
- B. Placing a hot water bottle on top of her hands
- C. Immersing her hands in comfortably hot water
- D. Extending her hands over a heat source, e.g., register or stove
Correct Answer: C
Rationale: Immersion in warm water provides even heat distribution, reducing stiffness and pain.