The nurse is caring for an older adult who is confused and restless. The nurse reviews the patient's history and recent complete blood count (CBC). Which finding may best explain the patient's confusion and restlessness?

Decreased hematocrit and hemoglobin.

Increased erythrocyte count

Normochromic red blood cells

Decreased thrombocytes.

Answer and Explanation

The Correct Answer is A

Choice A reason: Decreased hematocrit and hemoglobin indicate anemia, which is a condition where the blood does not carry enough oxygen to the tissues. This can cause symptoms such as confusion, restlessness, fatigue, and weakness in older adults.

Choice B reason: Increased erythrocyte count, or polycythemia, is a condition where the blood has too many red blood cells. This can cause the blood to become thick and viscous, which can impair blood flow and oxygen delivery. However, this is not the best explanation for the patient's confusion and restlessness, as polycythemia usually causes symptoms such as headache, dizziness, itching, and flushing.

Choice C reason: Normochromic red blood cells are red blood cells that have a normal color and hemoglobin content. This is not a finding that would explain the patient's confusion and restlessness, as it indicates a normal red blood cell function.

Choice D reason: Decreased thrombocytes, or platelets, are blood cells that help with clotting. This is a finding that would increase the risk of bleeding, but not the risk of confusion and restlessness. Decreased thrombocytes can cause symptoms such as bruising, bleeding gums, nosebleeds, and petechiae.

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Correct Answer is B

Explanation

Choice A reason: This is incorrect. Numbness of the fingers is not an early sign of a migraine with an aura, but rather a symptom of a sensory aura, which occurs after the visual aura and before the headache. A sensory aura is a tingling or numb sensation that affects one side of the body, usually the face, arm, or hand.

Choice B reason: This is correct. Visual disturbances are an early sign of a migraine with an aura, which precedes the headache by 10 to 60 minutes. A visual aura is a temporary change in vision, such as seeing flashes, zigzags, blind spots, or shimmering shapes.

Choice C reason: This is incorrect. Lethargy is not an early sign of a migraine with an aura, but rather a symptom of the postdrome phase, which occurs after the headache subsides. The postdrome phase is a period of recovery, where the patient may feel tired, weak, or confused.

Choice D reason: This is incorrect. Vertigo is not an early sign of a migraine with an aura, but rather a symptom of a vestibular migraine, which is a type of migraine that affects the balance and hearing. Vertigo is a sensation of spinning or dizziness that may occur with or without a headache.

A. The foot remains in the same position prior to stroking the sole of the foot. B. Great toe bends upward and smaller toes fan outward. C. Great toe bends downward. D. The opposite foot assumes the same position as the foot being stroked.

Correct Answer is B

Explanation

Choice A reason: This is incorrect. The foot remaining in the same position prior to stroking the sole of the foot is a normal response in adults. It indicates that the spinal cord and the brain are intact and functioning properly.

Choice B reason: This is correct. Great toe bending upward, and smaller toes fanning outward is an abnormal response in adults. It indicates a positive Babinski reflex, which is a sign of damage to the cerebral cortex or the pyramidal tract. The cerebral cortex is the outer layer of the brain that controls higher functions such as thinking, reasoning, and movement. The pyramidal tract is a bundle of nerve fibers that connects the cerebral cortex to the spinal cord and controls voluntary movements.

Choice C reason: This is incorrect. Great toe bending downward is also a normal response in adults. It indicates that the spinal cord and the brain are intact and functioning properly.

Choice D reason: This is incorrect. The opposite foot assuming the same position as the foot being stroked is not related to the Babinski reflex. It is a phenomenon called mirror movement, which may occur in some people due to genetic or developmental factors. It does not indicate any abnormality in the cerebral cortex.

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The nurse is caring for an older adult who is confused and restless. The nurse reviews the patient's history and recent complete blood count (CBC). Which finding may best explain the patient's confusion and restlessness?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses a client with a history of migraine headaches. Which clinical manifestation would the nurse identify as an early sign of a migraine with an aura?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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