ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 36 Questions
Question 1 of 5
The nurse provides care for a client who is comatose and needs to collect motor response data. Which nursing action is appropriate?
Correct Answer: C
Rationale: Assessment of motor function includes muscle movement, size, tone, strength, and coordination. The nurse evaluates motor response in the comatose or unconscious client by administering a painful stimulus to determine the client's response. An appropriate response is for the client to reach toward or withdraw from the stimulus. The Romberg test is used to assess equilibrium in a noncomatose client. Observing the reaction of the client's pupils to light is an oculomotor cranial nerve assessment. Monitoring sensitivity to temperature, touch, and pain assesses the sensory function of the client and not motor response.
Question 2 of 5
A client undergoes a scheduled electroencephalogram (EEG). Which post-procedure activity is most appropriate?
Correct Answer: C
Rationale: After an EEG, the nurse should ensure rest for the sleep-deprived client and allow the client to wash hair to remove the glue used to affix electrodes to the scalp. The client is advised not to take sedative drugs and caffeine-related drinks before the EEG; therefore, there is no reason to provide the client with them after the test. The nurse should not measure the LOC, the heart rate, or the pulse rate of the client unless advised by the health care provider.
Question 3 of 5
The nurse is caring for a client who is undergoing single-photon emission computed tomography (SPECT). What is a potential side effect that this client may suffer?
Correct Answer: C
Rationale: SPECT obtains images of the brain after the client intravenously receives radiopharmaceuticals and radioisotopes approximately 1 hour before the test begins. A potential risk of SPECT is the client's allergic reaction to the imaging material. Headache is an aftereffect of a cisternal puncture, and claustrophobia is experienced by clients during a magnetic resonance imaging scan.
Question 4 of 5
Which neurons transmit impulses from the CNS?
Correct Answer: D
Rationale: Neurons are either sensory or motor. Sensory neurons transmit impulses to the CNS; motor neurons transmit impulses from the CNS. A membranous sheath called the neurilemma covers the myelin of axons in peripheral nerves. Dendrites are nerve fibers.
Question 5 of 5
A critical care nurse is documenting the assessment of a client. The client is status postresection of a brain tumor. The nurse documents that the client is flaccid on the left. This means that the client:
Correct Answer: B
Rationale: Flaccidity is when the client has no motor response to stimuli. Flaccidity is a motor assessment.