Nokea
The client is being admitted to rule out a brain tumor. Which classic triad of symptoms supports a diagnosis of brain tumor?
- A. Nervousness, metastasis to the lungs, and seizures.
- B. Headache, vomiting, and papilledema.
- C. Hypotension, tachycardia, and tachypnea.
- D. Abrupt loss of motor function, diarrhea, and changes in taste.
Correct Answer: B
Rationale: The classic triad for brain tumors is headache, vomiting, and papilledema (B), due to increased ICP. Other options include unrelated or less specific symptoms.
You may also like to solve these questions
The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care?
- A. Observe the client swallowing for possible aspiration.
- B. Position the client in a semi-Fowler's position when sleeping.
- C. Place a suction setup at the client's bedside during meals.
- D. Refer the client to an occupational therapist for evaluation.
Correct Answer: D
Rationale: Agnosia is the inability to recognize objects, people, or sounds, impacting functional abilities. Referring to an occupational therapist (D) is appropriate to assess and develop strategies for managing agnosia. Swallowing issues (A, C) are related to dysphagia, not agnosia, and semi-Fowler’s position (B) is not specific to agnosia management.
Which nursing intervention is best during the confusedness?
- A. Reading a newspaper or magazine to the client
- B. Informing the client that confusion is temporary
- C. Withholding verbal communication temporarily
- D. Reorienting the client to place and situation
Correct Answer: D
Rationale: Reorienting the client to place and situation reduces confusion and promotes safety post-craniotomy.
The concept of intracranial regulation is identified for a client diagnosed with a brain tumor. Which intervention should the nurse include in the client’s plan of care?
- A. Tell the client to remain on bedrest.
- B. Maintain the intravenous rate at 150 mL/hour.
- C. Provide a soft, bland diet with three (3) snacks per day.
- D. Place the client on seizure precautions.
Correct Answer: D
Rationale: Brain tumors increase seizure risk, so seizure precautions (D) are essential. Bedrest (A) is unnecessary unless indicated, IV rate (B) depends on status, and diet (C) is not specific to intracranial regulation.
The client is diagnosed with meningococcal meningitis. Which preventive measure would the nurse expect the health-care provider to order for the significant others in the home?
- A. The Haemophilus influenzae vaccine.
- B. Antimicrobial chemoprophylaxis.
- C. A 10-day dose pack of corticosteroids.
- D. A gamma globulin injection.
Correct Answer: B
Rationale: Close contacts of meningococcal meningitis patients require antimicrobial chemoprophylaxis (B), such as rifampin, to prevent infection. Vaccines (A) are not for immediate prophylaxis, corticosteroids (C) treat inflammation, and gamma globulin (D) is not indicated.
Which instruction should the nurse include for a client taking phenytoin (Dilantin)?
- A. Brush teeth gently to prevent gum hyperplasia.
- B. Avoid grapefruit juice.
- C. Take the medication with milk.
- D. Increase dietary sodium intake.
Correct Answer: A
Rationale: Phenytoin can cause gingival hyperplasia; gentle brushing helps prevent gum complications.