Answers | Latest Update 2026/2027 |
Graded A+.
During .an .assessment .of .a .32-year-old .patient .with .a .recent
.head .injury, .the .nurse .notices .that .the .patient .responds .to
.pain .by .extending, .adducting, .and .internally .rotating .his
.arms. .His .palms .pronate .and .his .lower .extremities .extend
.with .plantar .flexion. .Which .of .these .statements .about .these
.findings .is .accurate?
a. .This .indicates .a .lesion .of .the .cerebral .cortex. .
b. .This .indicates .a .completely .nonfunctional .brainstem
c. .This .is .a .normal .response .that .will .go .away .in .24 .to .48
.hours
d. .This .is .a .very .ominous .sign .and .may .indicate .brainstem
.injury .- .ANS✓✓-d. .This .is .a .very .ominous .sign .and .may
.indicate .brainstem .injury
During .the .history .of .a .78-year-old .man, .his .wife .states .that
.he .occasionally .has .problems .with .short-term .memory .loss
.and .confusion: ."He .can't .even .remember .how .to .button .his
.shirt." .In .doing .the .assessment .of .his .sensory .system,
.which .action .by .the .nurse .is .most .appropriate?
a. .The .nurse .would .not .do .this .part .of .the .examination
.because .results .would .not .be .valid
,b. .The .nurse .would .perform .the .tests, .knowing .that .mental
.status .does .not .affect .sensory .ability
c. .The .nurse .would .proceed .with .the .explanations .of .each
.test, .making .sure .the .wife .understands
d. .Before .testing, .the .nurse .would .assess .the .patient's
.mental .status .and .ability .to .follow .directions .at .this .time .-
.ANS✓✓-
During .the .assessment .of .an .80-year-old .patient, .the .nurse
.notices .that .his .hands .show .tremors .when .he .reaches .for
.something .and .his .head .is .always .nodding. .There .is .no
.associated .rigidity .with .movement. .Which .of .these
.statements .is .most .accurate?
a. .These .are .normal .findings .resulting .from .aging
b. .These .could .be .related .to .hyperthyroidism
c. .there .are .the .result .of .Parkinson .disease
d. .This .patient .should .be .evaluated .for .a .cerebellar .lesion .-
.ANS✓✓-a. .These .are .normal .findings .resulting .from .aging
During .an .assessment .of .an .80-year-old .patient, .the .nurse
.notices .the .following: .inability .to .identify .vibrations .at .the
.ankle .and .to .identify .position .of .big .toe, .slower .and .more
.deliberate .gait, .and .slightly .impaired .tactile .sensation. .All
,.other .neurologic .findings .are .normal. .The .nurse .should
.interpret .that .these .findings .indicate:
a. .cranial .nerve .dysfunction
b. .lesion .in .the .cerebral .cortex
c. .normal .changes .due .to .aging
d. .demyelinization .of .nerves .due .to .a .lesion .- .ANS✓✓-c.
.normal .changes .due .to .aging
When .assessing .aging .adults, .the .nurse .knows .that .one .of
.the .first .things .that .should .be .assessed .before .making
.judgments .about .their .mental .status .is: .
a. .the .presence .of .phobias
b. .their .general .intelligence
c. .the .presence .of .irrational .thinking .patterns
d. .their .sensory-perceptive .abilities .- .ANS✓✓-d. .their
.sensory- .perceptive .abilities
A .19-year-old .woman .comes .to .the .clinic .at .the .insistence .of
.her .brother. .She .is .wearing .black .combat .boots .and .a
.black .lace .nightgown .over .the .top .of .her .other .clothes. .Her
.hair .is .dyed .pink .with .black .streaks .throughout. .She .has
.several .pierced .holes .in .her .nares .and .ears .and .is .wearing
, .an .earring .through .her .eyebrow .and .heavy .black .makeup.
.The .nurse .concludes:
a. .she .probably .doesn't .have .any .problems .at .all
b. .she .is .just .trying .to .shock .people .and .her .dress .should .be
.ignored
c. .she .has .manic .syndrome .because .of .her .abnormal .dress
.and .grooming
d. .that .more .information .should .be .gathered .to .decide
.whether .her .dress .is .appropriate .- .ANS✓✓-d. .that .more
.information .should .be .gathered .to .decide .whether .her
.dress .is .appropriate
A .patient .drifts .off .to .sleep .when .she .is .not .being
.stimulated. .The .nurse .can .arouse .her .easily .when .calling
.her .name, .but .she .remains .drowsy .during .the .conversation.
.The .best .description .of .this .patient's .level .of .consciousness
.would .be: .
a. .lethargic
b. .obtunded
c. .stuporous
d. .semialert .- .ANS✓✓-a. .lethargic
A .patient .has .been .in .the .intensive .care .unit .for .10 .days.
.He .has .just .been .moved .to .the .medical-surgical .unit, .and