Nokea
You are supervising a senior nursing student who is caring for a patient with a right hemisphere stroke. Which action by the student nurse requires that you intervene?
- A. The student instructs the patient to sit up straight, resulting in the patient's puzzled expression.
- B. The student moves the patient's tray to the right side of her over-bed tray.
- C. The student assists the patient with passive range-of-motion (ROM) exercises.
- D. The student combs the left side of the patient's hair when the patient combs only the right side.
Correct Answer: A
Rationale: Right hemisphere strokes can impair spatial perception; instructions may need to be simplified or demonstrated.
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Which of the following is a branch of the mandibular nerve
- A. Infraorbital nerve
- B. External nasal nerve
- C. Zygomaticofacial nerve
- D. Auricolotemporal nerve
Correct Answer: D
Rationale: The auriculotemporal nerve is a branch of the mandibular division (V3) of the trigeminal nerve. It supplies sensation to the temple and external ear.
While gathering equipment after an injection, a nurse accidentally received a prick from an improperly capped needle. To interpret this sensation, which of these areas must be intact?
- A. Corticospinal tract, medulla, and basal ganglia
- B. Pyramidal tract, hypothalamus, and sensory cortex
- C. Lateral spinothalamic tract, thalamus, and sensory cortex
- D. Anterior spinothalamic tract, basal ganglia, and sensory cortex
Correct Answer: C
Rationale: The correct answer is C: Lateral spinothalamic tract, thalamus, and sensory cortex. The lateral spinothalamic tract carries pain and temperature sensations to the thalamus, which then relays it to the sensory cortex for interpretation. In this scenario, the nurse's sensation of being pricked by the needle is a pain sensation, so the intactness of the lateral spinothalamic tract, thalamus, and sensory cortex is crucial for interpreting this sensation.
Choices A, B, and D are incorrect because they do not involve the specific pathways responsible for transmitting pain sensations. The corticospinal tract (choice A) is involved in motor function, the pyramidal tract (choice B) is involved in voluntary movement, and the anterior spinothalamic tract (choice D) is not associated with pain and temperature sensations. Therefore, the correct answer is C as it directly relates to the interpretation of the pain sensation experienced by the nurse.
Following a knee arthroplasty, a patient has a continuous passive motion machine for the affected joint. The nurse explains to the patient that this device is used for what purpose?
- A. To relieve edema and pain at the incision site
- B. To promote early joint mobility and increase knee flexion
- C. To prevent venous stasis and the formation of a deep venous thrombosis
- D. To improve arterial circulation to the affected extremity to promote healing
Correct Answer: B
Rationale: Continuous passive motion enhances joint mobility.
What is the most important method of diagnosing functional headaches?
- A. CT scan
- B. Electromyography (EMG)
- C. Cerebral blood flow studies
- D. Thorough history of the headache
Correct Answer: D
Rationale: A thorough history is critical for diagnosing functional headaches
An older female client experiences a musculoskeletal injury to her hip. Which of the following methods would help a nurse identify any swelling in the client?
- A. Asking questions of the client to assess the severity of pain
- B. Palpating the muscles and joints
- C. Asking the client to move the injured area as much as possible
- D. Observing the client for any involuntary movements
Correct Answer: B
Rationale: Palpation is a direct method to assess swelling and other physical changes.