Nokea
A patient has been admitted to the neurologic ICU with a diagnosis of a brain tumor. The patient is scheduled to have a tumor resection/removal in the morning. Which of the following assessment parameters should the nurse include in the initial assessment?
- A. Gag reflex
- B. Deep tendon reflexes
- C. Abdominal girth
- D. Hearing acuity
Correct Answer: A
Rationale: Assessing gag reflex is critical preoperatively to prevent aspiration during surgery. Other assessments are less relevant to immediate surgical risks.
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An older adult has encouraged her husband to visit their primary care provider, stating that she is concerned that he may have Parkinsons disease. Which of the wifes descriptions of her husbands health and function is most suggestive of Parkinsons disease?
- A. Lately he seems to move far more slowly than he ever has in the past.
- B. He often complains that his joints are terribly stiff when he wakes up in the morning.
- C. Hes forgotten the names of some people that weve known for years.
- D. Hes losing weight even though he has a ravenous appetite.
Correct Answer: A
Rationale: Bradykinesia is a hallmark of Parkinson's disease. Joint stiffness, memory loss, or weight loss with increased appetite are not typical symptoms.
A patient newly diagnosed with a cervical disk herniation is receiving health education from the clinic nurse. What conservative management measures should the nurse teach the patient to implement?
- A. Perform active ROM exercises three times daily.
- B. Sleep on a firm mattress.
- C. Apply cool compresses to the back of the neck daily.
- D. Wear the cervical collar for at least 2 hours at a time.
Correct Answer: B
Rationale: Sleeping on a firm mattress promotes proper spinal alignment and pain relief. Active ROM, cool compresses, and limited collar use are not standard conservative measures.
A patient who has been experiencing numerous episodes of unexplained headaches and vomiting has subsequently been referred for testing to rule out a brain tumor. What characteristic of the patients vomiting is most consistent with a brain tumor?
- A. The patients vomiting is accompanied by epistaxis.
- B. The patients vomiting does not relieve his nausea.
- C. The patients vomiting is unrelated to food intake.
- D. The patients emesis is blood-tinged.
Correct Answer: C
Rationale: Brain tumor-related vomiting is typically unrelated to food intake due to increased ICP. Epistaxis, blood-tinged emesis, or nausea relief are not characteristic.
A patient has just been diagnosed with Parkinsons disease and the nurse is planning the patients subsequent care for the home setting. What nursing diagnosis should the nurse address when educating the patients family?
- A. Risk for infection
- B. Impaired spontaneous ventilation
- C. Unilateral neglect
- D. Risk for injury
Correct Answer: D
Rationale: Parkinson's disease increases fall risk due to dyskinesia and bradykinesia, making 'risk for injury' a priority. Infection, ventilation, or neglect are not typical concerns.
A patient with an inoperable brain tumor has been told that he has a short life expectancy. On what aspects of assessment and care should the home health nurse focus? Select all that apply.
- A. Pain control
- B. Management of treatment complications
- C. Interpretation of diagnostic tests
- D. Assistance with self-care
- E. Administration of treatments
Correct Answer: A,B,D,E
Rationale: Home care for inoperable brain tumors focuses on pain control, complication management, self-care assistance, and treatment administration. Diagnostic test interpretation is not a nursing role.