Nokea
A patient is recovering from intracranial surgery that was performed using the transsphenoidal approach. The nurse should be aware that the patient may have required surgery on what neurologic structure?
- A. Cerebellum
- B. Hypothalamus
- C. Pituitary gland
- D. Pineal gland
Correct Answer: C
Rationale: The transsphenoidal approach accesses the pituitary gland via the nasal cavity. The cerebellum, hypothalamus, and pineal gland are not reached this way.
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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.
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 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.
When caring for a patient with increased ICP the nurse knows the importance of monitoring for possible secondary complications, including syndrome of inappropriate antidiuretic hormone (SIADH). What nursing interventions would the nurse most likely initiate if the patient developed SIADH?
- A. Fluid restriction
- B. Transfusion of platelets
- C. Transfusion of fresh frozen plasma (FFP)
- D. Electrolyte restriction
Correct Answer: A
Rationale: SIADH causes fluid overload, requiring fluid restriction and electrolyte monitoring. Platelet or plasma transfusions and electrolyte restriction are not indicated.
A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the patients plan of care?
- A. Monitoring of pulse oximetry
- B. Administration of a low-protein diet
- C. Administration of thorough oral hygiene
- D. Fluid restriction as ordered
Correct Answer: C
Rationale: Phenytoin can cause gingival hyperplasia, making thorough oral hygiene essential. Pulse oximetry, low-protein diet, and fluid restriction are not related to phenytoin's adverse effects.