Nursing Elites

1. After experiencing a left frontal lobe CVA, a fifty-five-year-old man is being monitored by a nurse. The patient's family is not present in the room. What should the nurse observe most closely for?

• A. Changes in emotion and behavior
• B. Monitor loss of hearing
• C. Observe appetite and vision deficits
• D. Changes in facial muscle control

Correct answer: A

Rationale: The correct answer is to watch for changes in emotion and behavior. The frontal lobe, particularly the left side, is responsible for regulating behavior and emotions. Therefore, following a left frontal lobe CVA, monitoring for alterations in emotion and behavior is crucial. Choices B, C, and D are incorrect because loss of hearing, appetite and vision deficits, and changes in facial muscle control are not directly associated with a left frontal lobe CVA.

2. One of the major functions of the kidneys in maintaining normal fluid balance is:

• A. the manufacture of antidiuretic hormone.
• B. the regulation of calcium and phosphate balance.
• C. the regulation of the pH of the extracellular fluid.
• D. the control of aldosterone levels.

Correct answer: C

Rationale: The correct answer is 'the regulation of the pH of the extracellular fluid.' The kidneys play a crucial role in maintaining normal fluid balance by regulating extracellular fluid and osmolarity through selective retention and excretion of fluids. Additionally, they regulate the pH of the extracellular fluid by retaining hydrogen ions and excreting metabolic wastes and toxic substances. Choice A is incorrect because antidiuretic hormone (ADH) is manufactured by the pituitary gland, not the kidneys. Choice B is incorrect as the regulation of calcium and phosphate balance is primarily controlled by the parathyroid gland. Choice D is incorrect as aldosterone levels are controlled by the adrenal glands, not the kidneys.

3. A patient has been prescribed Tegretol for the first time. Which of the following side effects is not associated with Tegretol?

• A. Sore throat
• B. Vertigo
• C. Fever
• D. Shortness of breath

Correct answer: D

Rationale: The correct answer is 'Shortness of breath.' Side effects commonly associated with Tegretol include sore throat, vertigo, and fever. Shortness of breath is not a typical side effect of Tegretol use. Sore throat, vertigo, and fever are known side effects of Tegretol, while shortness of breath is not typically linked to its use.

4. Which nursing diagnosis has the highest priority for a client with insomnia?

• A. Ineffective breathing pattern
• B. Disturbed sensory perception
• C. Ineffective coping
• D. Sleep deprivation

Correct answer: A

Rationale: The correct answer is 'A: Ineffective breathing pattern.' When a client presents with insomnia, assessing for underlying causes is crucial. Sleep apnea, an airway issue, may be a contributing factor to the client's insomnia, making 'Ineffective breathing pattern' the priority. 'Disturbed sensory perception' focuses on alterations in touch, taste, or vision, which are not directly related to insomnia. 'Ineffective coping' addresses a client's inability to manage stress, which, although important, is not the priority in this case. 'Sleep deprivation' is a consequence of insomnia rather than a primary nursing diagnosis.

5. A nurse suspects a patient is developing Bell's Palsy. The nurse wants to test the function of cranial nerve VII. Which of the following would be the most appropriate testing procedures?

• A. Test the taste sensation over the back of the tongue and activation of the facial muscles.
• B. Test the taste sensation over the front of the tongue and activation of the facial muscles.
• C. Test the sensation of the facial muscles and sensation of the back of the tongue.
• D. Test the sensation of the facial muscles and sensation of the front of the tongue.

Correct answer: B

Rationale: The facial nerve (VII) is responsible for motor function to the face and sensory function to the anterior two-thirds of the tongue. Therefore, to appropriately test the function of cranial nerve VII, the most appropriate testing procedures involve assessing the taste sensation over the front of the tongue (sensory) and activation of the facial muscles (motor). Option B, 'Test the taste sensation over the front of the tongue and activation of the facial muscles,' is the correct answer. Choices A, C, and D are incorrect because they do not involve the correct combination of sensory testing over the front of the tongue and motor activation of the facial muscles, which are key functions associated with cranial nerve VII.

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