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The nurse is caring for a patient whose recent health history includes an altered LOC. What should be the nurses first action when assessing this patient?
- A. Assessing the patients verbal response
- B. Assessing the patients ability to follow complex commands
- C. Assessing the patients judgment
- D. Assessing the patients response to pain
Correct Answer: A
Rationale: Verbal response assessment, via orientation to time, person, and place, is the initial step in evaluating altered LOC. Other assessments follow based on findings.
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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.
The nurse is participating in the care of a patient with increased ICP. What diagnostic test is contraindicated in this patients treatment?
- A. Computed tomography (CT) scan
- B. Lumbar puncture
- C. Magnetic resonance imaging (MRI)
- D. Venous Doppler studies
Correct Answer: B
Rationale: Lumbar puncture risks brain herniation in patients with increased ICP due to pressure changes. CT, MRI, and Doppler studies are safe and non-invasive.
A patient is recovering from intracranial surgery that was performed using the transsphenoidal approach. The nurse should be aware that the patient may have required surgery on what neurologic structure?
- A. Cerebellum
- B. Hypothalamus
- C. Pituitary gland
- D. Pineal gland
Correct Answer: C
Rationale: The transsphenoidal approach accesses the pituitary gland via the nasal cavity. The cerebellum, hypothalamus, and pineal gland are not reached this way.
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.
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.