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After reviewing a patient's cerebrospinal fluid (CSF) analysis, which of the following results is most important for the nurse to communicate to the health care provider?
- A. Specific gravity 1.007
- B. Protein 6.5 g/L
- C. White blood cell (WBC) count 5 x 10^6/L
- D. Glucose 2.5 mmol/L
Correct Answer: B
Rationale: The protein level is high. The specific gravity, WBCs, and glucose values are normal.
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When caring for a patient who has had cerebral angiography, which of the following nursing actions should be included in the plan of care?
- A. Ask about headache and photophobia.
- B. Keep patient NPO until gag reflex returns.
- C. Check pulse and blood pressure frequently.
- D. Assess orientation to person, place, and time.
Correct Answer: C
Rationale: Since a catheter is inserted into an artery (such as the femoral artery) during cerebral angiography, the nurse should assess for bleeding after this procedure. The other nursing assessments are not necessary after angiography.
Metoprolol, a β-adrenergic blocker that inhibits sympathetic nervous system activity, is prescribed for a patient. Which of the following assessments should the nurse monitor?
- A. Dry mouth
- B. Constipation
- C. Slowed pulse
- D. Urinary retention
Correct Answer: C
Rationale: Inhibition of the fight or flight response leads to decreased heart rate. Dry mouth, constipation, and urinary retention are associated with peripheral nervous system blockade.
The nurse notes in the patient's medical history that the patient has a positive Romberg test. Which of the following nursing diagnoses is appropriate?
- A. Acute pain related to physical injury agent (hyper-reflexia and spasm)
- B. Risk for falls as evidenced by impaired mobility
- C. Risk for autonomic dysreflexia as evidenced by spasm
- D. Ineffective thermoregulation related to inactivity
Correct Answer: B
Rationale: A positive Romberg test indicates that the patient has difficulty maintaining balance with the eyes closed. The Romberg does not test for autonomic dysreflexia, thermoregulation, or hyper-reflexia.
The nurse is developing a plan of care for a patient with dysfunction of the cerebellum. Which of the following goals of care should the nurse include?
- A. Prevent falls.
- B. Stabilize mood.
- C. Enhance swallowing ability.
- D. Improve short-term memory.
Correct Answer: A
Rationale: Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing ability.
The nurse is admitting a patient with a head injury who is acutely confused. Which of the following actions should the nurse take?
- A. Ask family members about the patient's health history.
- B. Ask leading questions to assist in obtaining health data.
- C. Wait until the patient is better oriented to ask questions.
- D. Obtain only the physiologic neurological assessment data.
Correct Answer: A
Rationale: When admitting a patient with confusion, the nurse should obtain health history information from others who have knowledge about the patient's health to obtain accurate data. Waiting until the patient is oriented or obtaining only physiological data will result in incomplete assessment data, this could adversely affect decision-making about treatment. Asking leading questions may result in inaccurate or incomplete information.