Nokea
The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of deficient fluid volume related to fluid restriction and osmotic diuretic use. What would be an appropriate intervention for this diagnosis?
- A. Change the patients position as indicated.
- B. Monitor serum electrolytes.
- C. Maintain NPO status.
- D. Monitor arterial blood gas (ABG) values.
Correct Answer: B
Rationale: Monitoring serum electrolytes adjusts fluid and electrolyte therapy in patients with deficient fluid volume post-craniotomy. Positioning, NPO status, and ABG monitoring do not directly address this diagnosis.
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The nurse is caring for a patient who is in status epilepticus. What medication does the nurse know may be given to halt the seizure immediately?
- A. Intravenous phenobarbital (Luminal)
- B. Intravenous diazepam (Valium)
- C. Oral lorazepam (Ativan)
- D. Oral phenytoin (Dilantin)
Correct Answer: B
Rationale: IV diazepam is used to stop status epilepticus immediately. Phenobarbital and phenytoin are for maintenance, and oral medications are inappropriate during active seizures.
A hospital patient has experienced a seizure. In the immediate recovery period, what action best protects the patients safety?
- A. Place the patient in a side-lying position.
- B. Pad the patients bed rails.
- C. Administer antianxiety medications as ordered.
- D. Reassure the patient and family members.
Correct Answer: B
Rationale: A side-lying position prevents aspiration of secretions post-seizure. Padding rails, antianxiety drugs, or reassurance are secondary to airway safety.
Following a traumatic brain injury, a patient has been in a coma for several days. Which of the following statements is true of this patients current LOC?
- A. The patient occasionally makes incomprehensible sounds.
- B. The patients current LOC will likely become a permanent state.
- C. The patient may occasionally make nonpurposeful movements.
- D. The patient is incapable of spontaneous respirations.
Correct Answer: C
Rationale: Coma patients may exhibit nonpurposeful movements to stimuli. Verbal sounds are rare, comas are not permanent, and spontaneous respirations may persist.
The nurse is caring for a patient with a brain tumor. What drug would the nurse expect to be ordered to reduce the edema surrounding the tumor?
- A. Solumedrol
- B. Dextromethorphan
- C. Dexamethasone
- D. Furosemide
Correct Answer: C
Rationale: Dexamethasone reduces edema around brain tumors. Solumedrol is less specific, furosemide is not ideal, and dextromethorphan is for cough suppression.
A patient has experienced a seizure in which she became rigid and then experienced alternating spasms and relaxation. What type of seizure does the nurse recognize?
- A. Unclassified seizure
- B. Absence seizure
- C. Generalized seizure
- D. Focal seizure
Correct Answer: C
Rationale: Generalized tonic-clonic seizures involve rigidity followed by spasms and relaxation. Absence seizures involve staring, focal seizures are localized, and unclassified seizures lack specific patterns.