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The critical care nurse is caring for a 25-year-old man admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this patient?
- A. Maintaining the patient's functional independence
- B. Providing health education
- C. Monitoring neurologic status closely
- D. Promoting mobility
Correct Answer: C
Rationale: Close neurologic monitoring is critical for brain abscess patients to detect changes like increased intracranial pressure. Independence, education, and mobility are secondary in acute care.
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The nurse caring for a patient diagnosed with Guillain-Barr?© syndrome is planning care with regard to the clinical manifestations associated with this syndrome. The nurse's communication with the patient should reflect the possibility of what sign or symptom of the disease?
- A. Intermittent hearing loss
- B. Tinnitus
- C. Tongue enlargement
- D. Vocal paralysis
Correct Answer: D
Rationale: Guillain-Barr?© syndrome affects the vagus nerve (X), potentially causing vocal paralysis or dysphagia. Hearing loss, tinnitus, and tongue enlargement are not associated.
To alleviate pain associated with trigeminal neuralgia, a patient is taking Tegretol (carbamazepine). What health education should the nurse provide to the patient before initiating this treatment?
- A. Concurrent use of calcium supplements is contraindicated.
- B. Blood levels of the drug must be monitored.
- C. The drug is likely to cause hyperactivity and agitation.
- D. Tegretol can cause tinnitus during the first few days of treatment.
Correct Answer: B
Rationale: Carbamazepine requires monitoring of blood levels to ensure therapeutic efficacy and avoid toxicity. It does not cause hyperactivity or tinnitus, and calcium supplements are not contraindicated.
The nurse is caring for a patient who is hospitalized with an exacerbation of MS. To ensure the patient's safety, what nursing action should be performed?
- A. Ensure that suction apparatus is set up at the bedside.
- B. Pad the patient's bed rails.
- C. Maintain bed rest whenever possible.
- D. Provide several small meals each day.
Correct Answer: A
Rationale: MS exacerbations increase aspiration risk due to dysphagia, so suction apparatus at the bedside is critical for safety. Bed rest should be minimized, and padding or small meals are not priority.
The nurse is developing a plan of care for a patient with Guillain-Barr?© syndrome. Which of the following interventions should the nurse prioritize for this patient?
- A. Using the incentive spirometer as prescribed
- B. Maintaining the patient on bed rest
- C. Providing aids to compensate for loss of vision
- D. Assessing frequently for loss of cognitive function
Correct Answer: A
Rationale: Incentive spirometry maximizes respiratory function, critical in Guillain-Barr?© due to potential respiratory muscle weakness. Bed rest increases complications, and vision or cognition are not typically affected.
A patient with diabetes presents to the clinic and is diagnosed with a mononeuropathy. This patient's nursing care should involve which of the following?
- A. Protection of the affected limb from injury
- B. Passive and active ROM exercises for the affected limb
- C. Education about improvements to glycemic control
- D. Interventions to prevent contractures
Correct Answer: A
Rationale: Mononeuropathy causes sensory loss, requiring protection of the affected limb from injury. ROM exercises, glycemic control education, and contracture prevention are not primary interventions.