Nokea
A nurse assesses a client with a brain tumor. Which newly identified assessment findings should alert the nurse to urgently communicate with the health care provider? (Select all that apply.)
- A. Glasgow Coma Scale score changes
- B. Abnormal flexion or extension
- C. Changes in cognition or speech
- D. Pinpoint, dilated, and nonreactive pupils
- E. Stable vital signs
Correct Answer: A,B,C,D
Rationale: Changes in Glasgow Coma Scale score, abnormal posturing, altered cognition or speech, and nonreactive pupils indicate neurological deterioration, requiring urgent provider notification. Stable vital signs do not necessitate immediate action.
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A nurse cares for a client who is recovering from a single-photon emission computed tomography (SPECT) with a radiopharmaceutical agent. Which statement should the nurse include when discussing the plan of care with this client?
- A. You may return to your previous activity level immediately.
- B. You are radioactive and must use a private bathroom.
- C. Frequent assessments of the injection site will be completed.
- D. We will be monitoring your renal function closely.
Correct Answer: A
Rationale: No special precautions are needed after SPECT, as radioisotopes are eliminated in urine without requiring monitoring or activity restrictions. The other options are unnecessary.
A nurse prepares a client for lumbar puncture (LP). Which assessment finding should alert the nurse to contact the health care provider?
- A. Shingles on the client's back
- B. Client is claustrophobic
- C. Absence of intravenous access
- D. Paroxysmal nocturnal dyspnea
Correct Answer: A
Rationale: Shingles at the puncture site increases infection risk, requiring the nurse to notify the provider. Claustrophobia, lack of IV access, or dyspnea can be managed without canceling the procedure.
A nurse assesses a client who demonstrates a positive Romberg's sign with eyes closed but not with eyes open. Which condition is most likely?
- A. Difficulty with proprioception
- B. Peripheral motor disorder
- C. Impaired cerebral function
- D. Positive pronator drift
Correct Answer: A
Rationale: A positive Romberg's sign with eyes closed but not with eyes open indicates difficulty with proprioception, as the client relies on vision to compensate for impaired position sense. The other options do not specifically describe this clinical finding.
A nurse teaches a client who is scheduled for a positron emission tomography scan of the brain. Which statement should the nurse include in this client's teaching?
- A. Avoid caffeine-containing substances for 12 hours before the test.
- B. Increase your fluid intake before and after the test.
- C. Do not take your cardiac medication the morning of the test.
- D. Remove your dentures and any metal before the test begins.
Correct Answer: A
Rationale: Caffeine is a central nervous system stimulant that may alter PET scan results, so it should be avoided for 12 hours prior. Increased fluid intake is unnecessary, cardiac medications should be continued, and metal removal is relevant for MRI, not PET.
A nurse cares for a client who is experiencing deteriorating neurologic function. The client states, 'I am worried I will not be able to care for my young children.' How should the nurse respond?
- A. Caring for your children is a priority. You may not want to ask for help, but you have to.
- B. Our community has resources that may help you with household tasks so you have energy to care for your children.
- C. You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?
- D. Give me more information about what worries you, so we can see if we can do something to make adjustments.
Correct Answer: D
Rationale: Exploring the client's specific concerns allows the nurse to tailor interventions and provide appropriate support. The other options make assumptions or suggest solutions without fully understanding the client's needs.