Nokea
A patient is postoperative day 1 following intracranial surgery. The nurses assessment reveals that the patients LOC is slightly decreased compared with the day of surgery. What is the nurses best response to this assessment finding?
- A. Recognize that this may represent the peak of post-surgical cerebral edema.
- B. Alert the surgeon to the possibility of an intracranial hemorrhage.
- C. Understand that the surgery may have been unsuccessful.
- D. Recognize the need to refer the patient to the palliative care team.
Correct Answer: A
Rationale: Cerebral edema peaks 24-36 hours post-surgery, often causing decreased LOC. Hemorrhage is not confirmed, surgery success is premature to judge, and palliative care is not indicated.
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A patient with increased ICP has a ventriculostomy for monitoring ICP. The nurses most recent assessment reveals that the patient is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication?
- A. Encephalitis
- B. CSF leak
- C. Meningitis
- D. Catheter occlusion
Correct Answer: C
Rationale: Nuchal rigidity and photophobia are signs of meningitis, a potential ventriculostomy complication. Encephalitis, CSF leak, and catheter occlusion present differently.
A nurse is collaborating with the interdisciplinary team to help manage a patients recurrent headaches. What aspect of the patients health history should the nurse identify as a potential contributor to the patients headaches?
- A. The patient leads a sedentary lifestyle.
- B. The patient takes vitamin D and calcium supplements.
- C. The patient takes vasodilators for the treatment of angina.
- D. The patient has a pattern of weight loss followed by weight gain.
Correct Answer: C
Rationale: Vasodilators are known to trigger headaches. Sedentary lifestyle, supplements, or weight fluctuations are not directly linked to recurrent headaches.
The nurse is caring for a patient who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this patient?
- A. Prednisone
- B. Dexamethasone
- C. Cafergot
- D. Phenytoin
Correct Answer: D
Rationale: Phenytoin is used prophylactically post-supratentorial surgery to prevent seizures. Prednisone and dexamethasone are steroids, and Cafergot treats migraines.
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.
While completing a health history on a patient who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state?
- A. Epileptic cry
- B. Confusion
- C. Urinary incontinence
- D. Body rigidity
Correct Answer: B
Rationale: Confusion is typical in the postictal state after a seizure. Epileptic cry, incontinence, and rigidity occur during the seizure, not afterward.