Nokea
The nurse is admitting a patient to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this patients admission orders? Select all that apply.
- A. Transcranial Doppler flow study
- B. Cerebral angiography
- C. MRI
- D. Cranial radiography
- E. Electromyelography
Correct Answer: A,B,C
Rationale: CT, MRI, cerebral angiography, and transcranial Doppler assess brain masses. Cranial radiography and EMG are not diagnostic for intracranial masses.
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A nurse is admitting a patient with a severe migraine headache and a history of acute coronary syndrome. What migraine medication would the nurse question for this patient?
- A. Rizatriptan (Maxalt)
- B. Naratriptan (Amerge)
- C. Sumatriptan succinate (Imitrex)
- D. Zolmitriptan (Zomig)
Correct Answer: C
Rationale: Sumatriptan and other triptans can cause chest pain and are contraindicated in ischemic heart disease. All listed medications are triptans, but sumatriptan is specifically noted for this risk.
A school nurse is called to the playground where a 6-year-old girl has been found unresponsive and staring into space, according to the playground supervisor. How would the nurse document the girls activity in her chart at school?
- A. Generalized seizure
- B. Absence seizure
- C. Focal seizure
- D. Unclassified seizure
Correct Answer: B
Rationale: Staring and unresponsiveness characterize an absence seizure, common in children. Generalized and focal seizures involve motor activity, and unclassified seizures lack clear patterns.
A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is admitted to the ED. The physician determines the patients injury is causing increased intracranial pressure (ICP). The nurse should gauge the patients LOC on the results of what diagnostic tool?
- A. Monro-Kellie hypothesis
- B. Glasgow Coma Scale
- C. Cranial nerve function
- D. Mental status examination
Correct Answer: B
Rationale: The Glasgow Coma Scale assesses LOC via eye, verbal, and motor responses, making it ideal for monitoring ICP-related changes. Other options are not specific to LOC assessment.
A patient is recovering from intracranial surgery performed approximately 24 hours ago and is complaining of a headache that the patient rates at 8 on a 10-point pain scale. What nursing action is most appropriate?
- A. Administer morphine sulfate as ordered.
- B. Reposition the patient in a prone position.
- C. Apply a hot pack to the patients scalp.
- D. Implement distraction techniques.
Correct Answer: A
Rationale: Severe post-craniotomy headache warrants morphine administration. Prone positioning increases ICP, hot packs may worsen pain, and distraction is inadequate for severe pain.
When caring for a patient with increased ICP the nurse knows the importance of monitoring for possible secondary complications, including syndrome of inappropriate antidiuretic hormone (SIADH). What nursing interventions would the nurse most likely initiate if the patient developed SIADH?
- A. Fluid restriction
- B. Transfusion of platelets
- C. Transfusion of fresh frozen plasma (FFP)
- D. Electrolyte restriction
Correct Answer: A
Rationale: SIADH causes fluid overload, requiring fluid restriction and electrolyte monitoring. Platelet or plasma transfusions and electrolyte restriction are not indicated.