Nokea
With regard to dermatomal nerve supply:
- A. C7 supplies the index finger
- B. The anterior axial line of the upper limb runs between C6 and C7
- C. T6 is at the level of the nipple
- D. The umbilicus is supplied by either T12 or L1
Correct Answer: C
Rationale: The T6 dermatome corresponds to the level of the nipple. Dermatomes are specific regions of skin supplied by sensory fibers from a single spinal nerve.
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What is a nursing intervention that is indicated for the patient with hemiplegia?
- A. The use of a footboard to prevent plantar flexion
- B. Immobilization of the affected arm against the chest with a sling
- C. Positioning the patient in bed with each joint lower than the joint proximal to it
- D. Having the patient perform passive range of motion (ROM) of the affected limb with the unaffected limb
Correct Answer: A
Rationale: Using a footboard helps prevent contractures and deformities in patients with hemiplegia
Which of the following is not a realistic outcome to establish with a client who has multiple sclerosis (MS)? The client will develop:
- A. Joint mobility
- B. Muscle strength
- C. Cognition
- D. Mood elevation
Correct Answer: B
Rationale: While joint mobility, cognition, and mood elevation can be improved or maintained, muscle strength is often progressively affected by MS and may not be fully restored.
While making a home visit she complains to you of experiencing increasing joint stiffness. You learn she has been doing a lot of reading lately. Based on these data you conclude she
- A. needs to exercise involved joints periodically
- B. needs to take long walks twice a day
- C. is a chronic complainer
- D. needs to rest involved joints for one hour at a time
Correct Answer: A
Rationale: Regular exercise maintains joint flexibility and reduces stiffness.
The brain is protected by:
- A. the meninges.
- B. a cushion of fluid.
- C. the bony skull.
- D. All of the above.
Correct Answer: D
Rationale: The brain is protected by multiple layers of defense, including the meninges (protective membranes), cerebrospinal fluid (a cushioning fluid), and the bony skull. The meninges consist of three layersâ€â€dura mater, arachnoid mater, and pia materâ€â€that provide structural support and protection. Cerebrospinal fluid surrounds the brain and spinal cord, acting as a shock absorber. The skull provides a rigid barrier against physical injury. Together, these structures safeguard the brain from damage.
The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits:
- A. A positive Brudzinski's sign
- B. A negative Kernig's sign
- C. Absence of nuchal rigidity
- D. A Glascow Coma Scale score of 15
Correct Answer: A
Rationale: A positive Brudzinski's sign, where flexion of the neck causes involuntary flexion of the hips and knees, is a classic sign of meningitis. Meningitis is a potential complication after craniotomy due to the breach in the protective meninges, allowing pathogens to enter the central nervous system. Other signs include fever, headache, and nuchal rigidity.