Nokea
During the examination of an unconscious patient, the nurse observes that the patients pupils are fixed and dilated. What is the most plausible clinical significance of the nurses finding?
- A. It suggests onset of metabolic problems.
- B. It indicates paralysis on the right side of the body.
- C. It indicates paralysis of cranial nerve X.
- D. It indicates an injury at the midbrain level.
Correct Answer: D
Rationale: Fixed, dilated pupils suggest midbrain injury, often from increased ICP. Metabolic issues, unilateral paralysis, or CN X damage do not typically cause this finding.
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The nurse has created a plan of care for a patient who is at risk for increased ICP. The patients care plan should specify monitoring for what early sign of increased ICP?
- A. Disorientation and restlessness
- B. Decreased pulse and respirations
- C. Projectile vomiting
- D. Loss of corneal reflex
Correct Answer: A
Rationale: Disorientation and restlessness are early signs of increased ICP. Decreased pulse, vomiting, and loss of reflexes are later manifestations.
The nurse is caring for a patient with a brain tumor. What drug would the nurse expect to be ordered to reduce the edema surrounding the tumor?
- A. Solumedrol
- B. Dextromethorphan
- C. Dexamethasone
- D. Furosemide
Correct Answer: C
Rationale: Dexamethasone reduces edema around brain tumors. Solumedrol is less specific, furosemide is not ideal, and dextromethorphan is for cough suppression.
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.
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.
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.