Nokea
An adult patient has sought care for the treatment of headaches that have become increasingly severe and frequent over the past several months. Which of the following questions addresses potential etiological factors? Select all that apply.
- A. Are you exposed to any toxins or chemicals at work?
- B. How would you describe your ability to cope with stress?
- C. What medications are you currently taking?
- D. When was the last time you were hospitalized?
- E. Does anyone else in your family struggle with headaches?
Correct Answer: A,B,C, E
Rationale: Headaches are multifactorial; toxins, stress, medications, and family history contribute. Hospitalization is not a direct etiological factor.
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A patient has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication?
- A. Vigilant monitoring of fluid balance
- B. Continuous BP monitoring
- C. Serial arterial blood gases (ABGs)
- D. Monitoring of the patients airway for patency
Correct Answer: A
Rationale: Diabetes insipidus causes extreme polyuria, requiring close fluid balance monitoring. BP, ABGs, and airway monitoring are less directly related.
A nurse is caring for a patient who experiences debilitating cluster headaches. The patient should be taught to take appropriate medications at what point in the course of a new headache?
- A. As soon as the pain becomes unbearable
- B. As soon as the patient senses the onset of symptoms
- C. Twenty to thirty minutes after the onset of symptoms
- D. When the patient senses his or her symptoms peaking
Correct Answer: B
Rationale: Early administration of medication at symptom onset aborts cluster headaches effectively. Delaying treatment prolongs pain unnecessarily.
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.
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.
The nurse caring for a patient in a persistent vegetative state is regularly assessing for potential complications. Complications of neurologic dysfunction for which the nurse should assess include which of the following? Select all that apply.
- A. Contractures
- B. Hemorrhage
- C. Pressure ulcers
- D. Venous thromboembolism
- E. Pneumonia
Correct Answer: A,C,D,E
Rationale: Immobility in a vegetative state increases risks for contractures, pressure ulcers, DVT, and pneumonia. Hemorrhage is not a common complication of decreased LOC.