Nokea
You are caring for a patient with a recurrent glioblastoma who is receiving dexamethasone (Decadron) 4 mg IV every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information concerns you the most?
- A. The patient does not recognize family members.
- B. The blood glucose level is 234 mg/dL.
- C. The patient complains of a continued headache.
- D. The daily weight has increased 1 kg.
Correct Answer: A
Rationale: Changes in recognition could indicate neurological deterioration requiring immediate attention.
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Which finding should the nursing assistant report immediately for a patient with a fractured femur?
- A. The patient complains of pain.
- B. The patient appears confused.
- C. The patient's blood pressure is 136/88.
- D. The patient voided using the bedpan.
Correct Answer: B
Rationale: Confusion could indicate a more serious underlying issue, such as reduced cerebral perfusion.
In a patient with a stable vertebral fracture, what should the nurse teach the patient to do?
- A. Remain on bed rest until the pain is gone.
- B. Logroll to keep the spine straight when turning.
- C. How to use bone cement to correct the problem.
- D. Take as much analgesic as needed to relieve the pain.
Correct Answer: B
Rationale: Logrolling minimizes further injury to the spine.
If a nurse observes a sudden change in a client's vital signs, what immediate step should the nurse take?
- A. Inform the physician
- B. Change the environmental settings of the client
- C. Alter the diet intake of the client
- D. Decrease the physical activity of the client
Correct Answer: A
Rationale: Immediate medical attention is necessary for significant changes in vital signs.
In evolutionary terms, which is the oldest part of the brain?
- A. the limbic system
- B. the cortex
- C. the right hemisphere
- D. the brain stem
Correct Answer: D
Rationale: The brainstem is the oldest part of the brain in evolutionary terms, as it is responsible for basic life-sustaining functions such as breathing, heart rate, and blood pressure. It includes structures like the medulla oblongata, pons, and midbrain. The brainstem has been conserved throughout evolution and is present in all vertebrates, making it a fundamental component of the central nervous system. In contrast, the cortex and limbic system evolved later and are more developed in higher mammals.
Regarding the cranial nerves
- A. The trigeminal nerve is purely sensory
- B. The abducens nerve traverses the foramen lacerum
- C. The trochlear nerve supplies the superior oblique muscle only
- D. The hypoglossal nerve exits the skull through the foramen magnum
Correct Answer: C
Rationale: The trochlear nerve (IV) innervates only the superior oblique muscle, which depresses and abducts the eye. It is the only cranial nerve that exits dorsally from the brainstem.