Nokea
The nurse is admitting a patient with a brain stem infarction. Which of the following assessments is priority?
- A. Reflex reaction time
- B. Pupil reaction to light
- C. Level of consciousness
- D. Respiratory rate and rhythm
Correct Answer: D
Rationale: Vital centres that control respiration are located in the medulla, and these are the priority assessments because changes in respiratory function may be life threatening. The other information also will be collected by the nurse, but it is not as urgent.
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The nurse is preparing a patient for a lumbar puncture. Which of the following actions should the nurse implement?
- A. Transfer the patient to radiology just before the procedure.
- B. Help the patient to a side lying position before the procedure.
- C. Place the patient on NPO status for 4 hours before the procedure.
- D. Administer a sedative medication 30 minutes before the procedure.
Correct Answer: B
Rationale: For a lumbar puncture, the patient lies in the lateral recumbent position. The procedure does not usually require a sedative, is done in the patient room, and has no risk for aspiration.
When caring for a patient who has had cerebral angiography, which of the following nursing actions should be included in the plan of care?
- A. Ask about headache and photophobia.
- B. Keep patient NPO until gag reflex returns.
- C. Check pulse and blood pressure frequently.
- D. Assess orientation to person, place, and time.
Correct Answer: C
Rationale: Since a catheter is inserted into an artery (such as the femoral artery) during cerebral angiography, the nurse should assess for bleeding after this procedure. The other nursing assessments are not necessary after angiography.
The nurse notes in the patient's medical history that the patient has a positive Romberg test. Which of the following nursing diagnoses is appropriate?
- A. Acute pain related to physical injury agent (hyper-reflexia and spasm)
- B. Risk for falls as evidenced by impaired mobility
- C. Risk for autonomic dysreflexia as evidenced by spasm
- D. Ineffective thermoregulation related to inactivity
Correct Answer: B
Rationale: A positive Romberg test indicates that the patient has difficulty maintaining balance with the eyes closed. The Romberg does not test for autonomic dysreflexia, thermoregulation, or hyper-reflexia.
The charge nurse is observing a novice staff nurse who is assessing a patient with a possible spinal cord lesion for sensation. Which of the following action indicates a need for further teaching about neurological assessment?
- A. The novice nurse asks the patient, 'Does this feel sharp?'
- B. The novice nurse tests for light touch before testing for pain.
- C. The novice nurse has the patient close the eyes during testing.
- D. The novice nurse uses an irregular pattern to test for intact touch.
Correct Answer: A
Rationale: When performing a sensory assessment, the nurse should not provide verbal clues. The other actions by the new nurse are appropriate.
After reviewing a patient's cerebrospinal fluid (CSF) analysis, which of the following results is most important for the nurse to communicate to the health care provider?
- A. Specific gravity 1.007
- B. Protein 6.5 g/L
- C. White blood cell (WBC) count 5 x 10^6/L
- D. Glucose 2.5 mmol/L
Correct Answer: B
Rationale: The protein level is high. The specific gravity, WBCs, and glucose values are normal.