Nokea
A school nurse is called to the playground where a 6-year-old girl has been found unresponsive and staring into space, according to the playground supervisor. How would the nurse document the girls activity in her chart at school?
- A. Generalized seizure
- B. Absence seizure
- C. Focal seizure
- D. Unclassified seizure
Correct Answer: B
Rationale: Staring and unresponsiveness characterize an absence seizure, common in children. Generalized and focal seizures involve motor activity, and unclassified seizures lack clear patterns.
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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.
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.
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 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 sustained a moderate head injury following a bicycle accident. The nurses most recent assessment reveals that the patients respiratory effort has increased. What is the nurses most appropriate response?
- A. Inform the care team and assess for further signs of possible increased ICP.
- B. Administer bronchodilators as ordered and monitor the patients LOC.
- C. Increase the patients bed height and reassess in 30 minutes.
- D. Administer a bolus of normal saline as ordered.
Correct Answer: A
Rationale: Increased respiratory effort may indicate rising ICP, requiring immediate team notification and further assessment. Bronchodilators, bed elevation, or saline are inappropriate initial actions.