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The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is 'brain dead.' Which data support that the client is brain dead?
- A. When the client's head is turned to the right, the eyes turn to the right.
- B. The electroencephalogram (EEG) has identifiable waveforms.
- C. No eye activity is observed when the cold caloric test is performed.
- D. The client assumes decorticate posturing when painful stimuli are applied.
Correct Answer: C
Rationale: Brain death is confirmed by absent brainstem reflexes, including no eye movement during the cold caloric test (C). Eyes turning with head movement (A) indicates intact reflexes, EEG waveforms (B) suggest brain activity, and decorticate posturing (D) indicates some brain function.
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Which assessment data would make the nurse suspect that the client with a C7 spinal cord injury is experiencing autonomic dysreflexia?
- A. Abnormal diaphoresis.
- B. A severe throbbing headache.
- C. Sudden loss of motor function.
- D. Spastic skeletal muscle movement.
Correct Answer: B
Rationale: Autonomic dysreflexia in SCI causes severe headache (B) due to hypertensive crisis from a trigger like bladder distention. Diaphoresis (A) is secondary, motor loss (C) is expected, and spasticity (D) is chronic.
The client diagnosed with breast cancer has developed metastasis to the brain. Which prophylactic measure should the nurse implement?
- A. Institute aspiration precautions.
- B. Refer the client to Reach to Recovery.
- C. Initiate seizure precautions.
- D. Teach the client about mastectomy care.
Correct Answer: C
Rationale: Brain metastases increase seizure risk, so seizure precautions (C) are appropriate. Aspiration precautions (A) are unrelated, Reach to Recovery (B) supports breast cancer recovery, and mastectomy care (D) is not relevant to brain metastases.
Which preoperative assessment is most important to document as a basis for postoperative comparison?
- A. Motor strength in all extremities
- B. Sodium and potassium laboratory values
- C. Pulses in lower extremities
- D. Glucometer blood glucose levels
Correct Answer: A
Rationale: Motor strength assessment provides a baseline to detect postoperative neurological deficits from brain tumor surgery.
The nurse is monitoring clients for development of a brain abscess. Which client would be the nurse’s lowest priority for monitoring for a brain abscess?
- A. Client with endocarditis
- B. Client with idiopathic epilepsy
- C. Client who had a liver transplant
- D. Client with meningitis
Correct Answer: B
Rationale: The client with endocarditis has an infective process within the body’s circulation and is at risk for septic emboli, which could progress to a brain abscess. The client who has idiopathic epilepsy has the lowest risk of developing a brain abscess because epilepsy from an unknown cause does not have the risk factors of an active infectious process or an impaired immune system. The client with the liver transplant is at risk for brain abscess because immunosuppressant medications depress the immune system. The client with meningitis has an infective process in close proximity to the brain and should be monitored for a brain abscess.
During the immediate postoperative assessment, the nurse notices the dressing is moist. Which action is most appropriate to take first?
- A. Change the dressing.
- B. Reinforce the dressing.
- C. Remove the dressing.
- D. Document the findings.
Correct Answer: B
Rationale: Reinforcing the dressing controls minor drainage and maintains sterility while further assessment is conducted.