Nokea
A patient has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication?
- A. Vigilant monitoring of fluid balance
- B. Continuous BP monitoring
- C. Serial arterial blood gases (ABGs)
- D. Monitoring of the patients airway for patency
Correct Answer: A
Rationale: Diabetes insipidus causes extreme polyuria, requiring close fluid balance monitoring. BP, ABGs, and airway monitoring are less directly related.
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A patient with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate?
- A. Restrain the patient to prevent injury.
- B. Open the patients jaws to insert an oral airway.
- C. Place patient in high Fowlers position.
- D. Loosen the patients restrictive clothing
Correct Answer: D
Rationale: Loosening restrictive clothing prevents injury during a seizure. Restraining or inserting an airway can cause harm, and high Fowlers is inappropriate during a seizure.
The nurse is caring for a patient with a brain tumor. What drug would the nurse expect to be ordered to reduce the edema surrounding the tumor?
- A. Solumedrol
- B. Dextromethorphan
- C. Dexamethasone
- D. Furosemide
Correct Answer: C
Rationale: Dexamethasone reduces edema around brain tumors. Solumedrol is less specific, furosemide is not ideal, and dextromethorphan is for cough suppression.
A patient is recovering from intracranial surgery performed approximately 24 hours ago and is complaining of a headache that the patient rates at 8 on a 10-point pain scale. What nursing action is most appropriate?
- A. Administer morphine sulfate as ordered.
- B. Reposition the patient in a prone position.
- C. Apply a hot pack to the patients scalp.
- D. Implement distraction techniques.
Correct Answer: A
Rationale: Severe post-craniotomy headache warrants morphine administration. Prone positioning increases ICP, hot packs may worsen pain, and distraction is inadequate for severe pain.
A nurse is caring for a patient who experiences debilitating cluster headaches. The patient should be taught to take appropriate medications at what point in the course of a new headache?
- A. As soon as the pain becomes unbearable
- B. As soon as the patient senses the onset of symptoms
- C. Twenty to thirty minutes after the onset of symptoms
- D. When the patient senses his or her symptoms peaking
Correct Answer: B
Rationale: Early administration of medication at symptom onset aborts cluster headaches effectively. Delaying treatment prolongs pain unnecessarily.
Following a traumatic brain injury, a patient has been in a coma for several days. Which of the following statements is true of this patients current LOC?
- A. The patient occasionally makes incomprehensible sounds.
- B. The patients current LOC will likely become a permanent state.
- C. The patient may occasionally make nonpurposeful movements.
- D. The patient is incapable of spontaneous respirations.
Correct Answer: C
Rationale: Coma patients may exhibit nonpurposeful movements to stimuli. Verbal sounds are rare, comas are not permanent, and spontaneous respirations may persist.