The client presents with a complaint of "always dropping things and falling down." During the neurologic assessment, the nurse notices the client is unable to perform rapid alternating movements. Instead the client's response is very slow and misses often. What neurologic dysfunction would the nurse suspect?
inability to understand directions
Lesion of cranial nerve IX
Dysfunction of the cerebellum
Vestibular disease
The Correct Answer is C
A. Inability to understand directions
The client's issue is with motor coordination, not comprehension.
B. Lesion of cranial nerve IX
Cranial nerve IX (Glossopharyngeal) is associated with swallowing and taste, not motor coordination.
C. Dysfunction of the cerebellum
The cerebellum controls coordination and fine motor movements. The client's inability to perform rapid alternating movements (dysdiadochokinesia) suggests cerebellar dysfunction.
D. Vestibular disease
Vestibular disorders cause dizziness, vertigo, and balance problems but do not typically affect rapid alternating movements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Gently cleanse the wounds with warm soapy water
Initial burn care focuses on preventing hypothermia and infection. Cleaning is usually performed in a controlled setting like a burn unit, not in the emergency phase.
B. Remove blistered skin and cover with a dry dressing
Blisters should not be removed in the initial phase unless they are large and tense. Removal increases the risk of infection.
C. Apply saline-soaked wet-to-dry dressings
Wet dressings can lead to hypothermia in burn patients, which worsens outcomes. Dry coverings are preferred.
D. Cover with a clean dry sheet to prevent hypothermia
Burn patients lose heat rapidly due to loss of skin integrity. Covering with a clean, dry sheet helps prevent hypothermia and infection before transfer.
Correct Answer is C
Explanation
A. Diphenhydramine 50 mg PO
Diphenhydramine (Benadryl) treats mild allergic reactions but is not sufficient for anaphylaxis. The presence of SOB and angioedema suggests airway compromise, requiring epinephrine.
B. Famotidine 40 mg PO
Famotidine (H2 blocker) can help with allergic reactions but is not the priority in an emergency.
C. Epinephrine 1 mg IM
Epinephrine is the first-line treatment for anaphylaxis. It reverses airway swelling, hypotension, and bronchoconstriction. The standard IM dose is 0.3-0.5 mg, not 1 mg, but epinephrine remains the priority drug.
D. A fluid bolus of normal saline
IV fluids help treat hypotension in anaphylaxis, but epinephrine is the priority intervention.
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