A nurse caring for a patient with a herniated lumbar disk develops a plan of care for impaired mobility related to nerve compression. Which patient outcome indicates that the plan has been successful?

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Question 1 of 5

A nurse caring for a patient with a herniated lumbar disk develops a plan of care for impaired mobility related to nerve compression. Which patient outcome indicates that the plan has been successful?

Correct Answer: D

Rationale: The correct answer is D: The patient is able to ambulate 25 feet without pain. This outcome indicates successful plan implementation for impaired mobility due to nerve compression. Ambulating without pain shows improved mobility and nerve compression relief. Choices A, B, and C do not directly address mobility improvement. Choice A focuses on pain level, which is important but not a direct measure of mobility. Choice B refers to upper extremities, not the lower extremities affected by lumbar disk herniation. Choice C addresses medication management, not mobility improvement.

Question 2 of 5

What is an important consideration regarding TPN administration?

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Aseptic technique prevents infection at IV site. 2. TPN is a high-risk solution, requiring strict aseptic administration. 3. Contaminated site can lead to sepsis or other serious complications. 4. Choice B increases risk of contamination. 5. Choice C increases risk of bacterial growth. 6. Choice D may introduce air or contamination. Summary: Choice A is correct as it emphasizes infection prevention. Choices B, C, and D pose risks of contamination, bacterial growth, or air introduction.

Question 3 of 5

An adult suffered a diving accident and is being brought in by an ambulance intubated and on backboard with a cervical collar. What is the first action the nurse would take on arrival in the hospital?

Correct Answer: C

Rationale: Upon arrival, checking the lungs for equal breath sounds bilaterally is the first action. This is crucial to assess airway patency and breathing effectiveness in a patient with a history of diving accident and intubation. Ensuring proper oxygenation takes precedence over other actions. Taking vital signs, inserting an IV line, and performing a neurologic check can wait until airway and breathing are adequately assessed.

Question 4 of 5

During the physical assessment, the nurse recalls that the areas most frequently affected by multiple sclerosis are the:

Correct Answer: C

Rationale: Rationale for Choice C (Correct Answer): 1. Multiple sclerosis (MS) commonly affects the optic nerve and chiasm. 2. MS is characterized by demyelination of nerves, leading to visual disturbances. 3. Optic nerve involvement results in vision problems, such as blurred vision. 4. Chiasm involvement can cause visual field deficits and color perception changes. Summary of Other Choices: A: Lateral, 3rd, and 4th ventricles - Incorrect. MS primarily affects the central nervous system, not ventricles. B: Pons, medulla, and cerebral peduncles - Incorrect. While these areas are part of the brainstem, they are not commonly affected in MS. D: Above areas - Incorrect. This choice is vague and does not specify any specific areas affected by MS.

Question 5 of 5

Mr. Reyea complains of hearing ringing noises. The nurse recognizes that this assessment suggests injury of the

Correct Answer: D

Rationale: The correct answer is D: Eight Cranial Nerve (Vestibulocochlear). Mr. Reyea's complaint of hearing ringing noises indicates a potential issue with his auditory function, which is primarily governed by the Vestibulocochlear nerve. This nerve is responsible for transmitting sound and balance information from the inner ear to the brain. The other choices, A: Frontal lobe, B: Six cranial nerve (abducent), and C: Occipital lobe, are not directly associated with auditory function or the perception of ringing noises in the ear.

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