Nokea
The client diagnosed with a brain tumor was admitted to the intensive care unit with decorticate posturing. Which indicates that the client’s condition is becoming worse?
- A. The client has purposeful movement with painful stimuli.
- B. The client has assumed adduction of the upper extremities.
- C. The client is aimlessly thrashing in the bed.
- D. The client has become flaccid and does not respond to stimuli.
Correct Answer: D
Rationale: Flaccid paralysis and unresponsiveness (D) indicate severe brain dysfunction or progression to brain death, worse than decorticate posturing. Purposeful movement (A) or thrashing (C) suggest improvement, and adduction (B) is not a standard indicator.
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The client admitted to the hospital to rule out encephalitis is being prepared for a lumbar puncture. Which instructions should the nurse teach the client regarding care postprocedure?
- A. Instruct that all invasive procedures require a written permission.
- B. Explain that this allows analysis of a sample of the cerebrospinal fluid.
- C. Tell the client to increase fluid intake to 300 mL for the next 48 hours.
- D. Discuss that lying supine with the head flat will prevent all hematomas.
Correct Answer: C
Rationale: Post-lumbar puncture, increasing fluid intake (C) helps replace CSF and prevent headaches. Consent (A) is preoperative, CSF analysis (B) explains purpose, and lying flat (D) prevents headaches, not hematomas.
To correctly perform the eye irrigation, the nurse instills the eye irrigant in which direction?
- A. In the lower conjunctiva toward the corneal surface
- B. From the outer canthus of the eye to the inner canthus
- C. From the nasal corner of the eye toward the temple
- D. From the margins of the eyelashes to the folds of the lids
Correct Answer: C
Rationale: Instilling irrigant from the inner canthus to the outer canthus follows the natural flow of tears, preventing contamination.
The student nurse asks the nurse, 'Why do you ask the client to identify how many fingers you have up when the client hit the front of the head, not the back?' The nurse would base the response on which scientific rationale?
- A. This is part of the routine neurological examination.
- B. This is done to determine if the client has diplopia.
- C. This assesses the amount of brain damage.
- D. This is done to indicate if there is a rebound effect on the brain.
Correct Answer: B
Rationale: Frontal head injuries may affect the occipital lobe or optic pathways, causing diplopia (double vision, B). Routine exams (A) are broader, brain damage (C) is not specific, and rebound effect (D) is not a term used here.
The client diagnosed with a gunshot wound to the head assumes decorticate posturing when the nurse applies painful stimuli. Which assessment data obtained three (3) hours later would indicate the client is improving?
- A. Purposeless movement in response to painful stimuli.
- B. Flaccid paralysis in all four extremities.
- C. Decerebrate posturing when painful stimuli are applied.
- D. Pupils that are 6 mm in size and nonreactive on painful stimuli.
Correct Answer: A
Rationale: Purposeless movement (A) indicates a higher level of brain function compared to decorticate posturing, suggesting improvement. Flaccid paralysis (B) or decerebrate posturing (C) indicates worsening, and nonreactive pupils (D) suggest severe brain damage.
The client is scheduled for an electroencephalogram (EEG) to help diagnose a seizure disorder. Which preprocedure teaching should the nurse implement?
- A. Tell the client to take any routine antiseizure medication prior to the EEG.
- B. Tell the client not to eat anything for eight (8) hours prior to the procedure.
- C. Instruct the client to stay awake for 24 hours prior to the EEG.
- D. Explain to the client that there will be some discomfort during the procedure.
Correct Answer: A
Rationale: Taking routine antiseizure medications (A) ensures therapeutic levels during the EEG, avoiding seizures that could skew results. Fasting (B) is unnecessary, sleep deprivation (C) may be used in specific cases but not routinely, and EEGs are painless (D).