ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 58 Questions
Question 1 of 5
The nurse is admitting a patient with a head injury who is acutely confused. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: When admitting a patient with confusion, the nurse should obtain health history information from others who have knowledge about the patient's health to obtain accurate data. Waiting until the patient is oriented or obtaining only physiological data will result in incomplete assessment data, this could adversely affect decision-making about treatment. Asking leading questions may result in inaccurate or incomplete information.
Question 2 of 5
A patient has a lesion that affects lower motor neurons. During assessment of the patient's lower extremities, which of the following findings should the nurse expect?
Correct Answer: B
Rationale: Because the cell bodies of lower motor neurons are directly affected, a lesion results in flaccidity, loss of muscle tone, and decreased reflexes. Spasticity and hyperactive reflexes are associated with upper motor neuron lesions. Loss of sensation is related to sensory nerve damage, not motor neuron lesions.
Question 3 of 5
Metoprolol, a β-adrenergic blocker that inhibits sympathetic nervous system activity, is prescribed for a patient. Which of the following assessments should the nurse monitor?
Correct Answer: C
Rationale: Inhibition of the fight or flight response leads to decreased heart rate. Dry mouth, constipation, and urinary retention are associated with peripheral nervous system blockade.
Question 4 of 5
Which of the following actions should the nurse implement to assess the functioning of the trigeminal and facial nerves (CN V and VII) in a patient?
Correct Answer: A
Rationale: The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is tested by having the patient read a Snellen chart or a newspaper. Assessment of pupil response to light and ptosis are used to check function of the oculomotor nerve.
Question 5 of 5
Neurological testing of the patient indicates impaired functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X). Which of the following actions should the nurse include in the plan of care?
Correct Answer: B
Rationale: The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex; a patient with impaired function of these nerves is at risk for aspiration. An oral airway may be needed when a patient is unconscious and unable to maintain the airway, but it will not decrease aspiration risk. Taste and eye blink are controlled by the facial nerve.