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The nurse is caring for a client with mid-to-late stage of an inoperable brain tumor. What teaching is most important for the nurse to do with this client?
- A. Optimizing nutrition
- B. Managing muscle weakness
- C. Explaining hospice care and services
- D. Offering family support groups
Correct Answer: C
Rationale: The nurse explains hospice care and services to clients with brain tumors that no longer are at a stage where they can be cured. Managing muscle weakness and offering family support groups are important, but explaining hospice is the best answer. Optimizing nutrition at this point is not a priority.
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The nurse is caring for a client with head trauma. Which assessment finding(s) would indicate an increasing intracranial pressure (ICP) in this client? Select all that apply.
- A. Stiff neck
- B. Generalized pain
- C. Glasgow Coma Scale of 15
- D. Elevated systolic blood pressure
- E. Brisk pupil response
- F. Wide pulse pressure
Correct Answer: D,F
Rationale: Elevated systolic blood pressure with widening pulse pressure is consistent with Cushing's triad, which occurs late in increasing ICP. Other signs of Cushing's triad include bradycardia and irregular breathing. Stiff neck is not a symptom associated with ICP. Generalized pain is not significant with ICP unless related to complaint of headache (especially upon awakening). Glasgow Coma Scale of 15 and brisk pupil response are normal findings.
The nurse is caring for a client with Bell palsy. Which of the following teaching points is a priority in the management of symptoms for this client?
- A. Avoid stimuli that trigger pain.
- B. Use ophthalmic lubricant and protect the eye.
- C. Encourage semiannual dental exams.
- D. Complete the course of antibiotics as prescribed.
Correct Answer: B
Rationale: The VII cranial nerve supplies muscles to the face. In Bell palsy, the eye can be affected which results in incomplete closure and risk for injury. The eye can become dry and irritated unless eye moisturizing drops and ophthalmic ointment is applied. Avoiding stimuli that can trigger pain is specific to tic douloureux (cranial nerve V disorder). Encouraging dental exams is a part of care but not the priority. Antibiotics are not used in the treatment of Bell's palsy because it is thought to be caused by a virus.
The school nurse notes a 6-year-old running across the playground with friends. The child stops in midstride, freezing for a few seconds. Then the child resumes running across the playground. The school nurse suspects what in this child?
- A. An absence seizure
- B. A myoclonic seizure
- C. A partial seizure
- D. A tonic-clonic seizure
Correct Answer: A
Rationale: Absence seizures, formerly referred to as petit mal seizures, are more common in children. They are characterized by a brief loss of consciousness during which physical activity ceases. The person stares blankly; the eyelids flutter; the lips move; and slight movement of the head, arms, and legs occurs. These seizures typically last for a few seconds, and the person seldom falls to the ground. Because of their brief duration and relative lack of prominent movements, these seizures often go unnoticed. People with absence seizures can have them many times a day. Partial, or focal, seizures begin in a specific area of the cerebral cortex. Both myoclonic and tonic-clonic seizures involve jerking movements.
An older client complains of a constant headache. A physical examination shows papilledema. Based on these symptoms, what condition would the nurse suspect?
- A. Epilepsy
- B. Trigeminal neuralgia
- C. Hypostatic pneumonia
- D. Brain tumor
Correct Answer: D
Rationale: Headache and papilledema are symptoms of a brain tumor, although these symptoms do appear less often in the older adult. Symptoms of epilepsy include seizure activity, whereas symptoms of trigeminal neuralgia would be pain in the jaws or facial muscles. Hypostatic pneumonia develops due to immobility or prolonged bed rest in older clients. The other options are not associated with papilledema or constant headache.
A client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure?
- A. Blood pressure 100/60 mm Hg
- B. Lethargy
- C. Nausea
- D. Periorbital edema
Correct Answer: B
Rationale: Decreasing level of consciousness is one of the earliest signs of increased intracranial pressure (ICP). Without a baseline for the blood pressure, it is difficult to determine whether this is a significant change for this client. Vomiting (usually without forewarning of nausea) when associated with a head injury suggests increasing ICP. Periorbital edema is more suggestive of fluid overload than ICP.