Nokea
A patient has experienced a seizure in which she became rigid and then experienced alternating spasms and relaxation. What type of seizure does the nurse recognize?
- A. Unclassified seizure
- B. Absence seizure
- C. Generalized seizure
- D. Focal seizure
Correct Answer: C
Rationale: Generalized tonic-clonic seizures involve rigidity followed by spasms and relaxation. Absence seizures involve staring, focal seizures are localized, and unclassified seizures lack specific patterns.
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The nurse is caring for a patient with permanent neurologic impairments resulting from a traumatic head injury. When working with this patient and family, what mutual goal should be prioritized?
- A. Achieve as high a level of function as possible.
- B. Enhance the quantity of the patients life.
- C. Teach the family proper care of the patient.
- D. Provide community assistance.
Correct Answer: A
Rationale: Maximizing function is the primary goal for neurologic impairment, encompassing quality of life and family/community involvement. Quantity of life is less relevant.
The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of ineffective cerebral tissue perfusion. What would be an expected outcome that the nurse would document for this diagnosis?
- A. Copes with sensory deprivation.
- B. Registers normal body temperature.
- C. Pays attention to grooming.
- D. Obeys commands with appropriate motor responses.
Correct Answer: D
Rationale: Obeying commands with appropriate motor responses indicates improved cerebral perfusion. Other outcomes relate to sensory perception, thermoregulation, or body image, not perfusion.
The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of deficient fluid volume related to fluid restriction and osmotic diuretic use. What would be an appropriate intervention for this diagnosis?
- A. Change the patients position as indicated.
- B. Monitor serum electrolytes.
- C. Maintain NPO status.
- D. Monitor arterial blood gas (ABG) values.
Correct Answer: B
Rationale: Monitoring serum electrolytes adjusts fluid and electrolyte therapy in patients with deficient fluid volume post-craniotomy. Positioning, NPO status, and ABG monitoring do not directly address this diagnosis.
A hospital patient has experienced a seizure. In the immediate recovery period, what action best protects the patients safety?
- A. Place the patient in a side-lying position.
- B. Pad the patients bed rails.
- C. Administer antianxiety medications as ordered.
- D. Reassure the patient and family members.
Correct Answer: B
Rationale: A side-lying position prevents aspiration of secretions post-seizure. Padding rails, antianxiety drugs, or reassurance are secondary to airway safety.
A patient has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the patients ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following?
- A. Hemiplegia
- B. Dry mucous membranes
- C. Signs of internal bleeding
- D. Loss of brain stem reflexes
Correct Answer: D
Rationale: Loss of brain stem reflexes (e.g., pupillary, corneal) signals impending death in severe head injury. Hemiplegia, dry membranes, and bleeding are not specific to this outcome.