Nokea
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.
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A patient is postoperative day 1 following intracranial surgery. The nurses assessment reveals that the patients LOC is slightly decreased compared with the day of surgery. What is the nurses best response to this assessment finding?
- A. Recognize that this may represent the peak of post-surgical cerebral edema.
- B. Alert the surgeon to the possibility of an intracranial hemorrhage.
- C. Understand that the surgery may have been unsuccessful.
- D. Recognize the need to refer the patient to the palliative care team.
Correct Answer: A
Rationale: Cerebral edema peaks 24-36 hours post-surgery, often causing decreased LOC. Hemorrhage is not confirmed, surgery success is premature to judge, and palliative care is not indicated.
A nurse is collaborating with the interdisciplinary team to help manage a patients recurrent headaches. What aspect of the patients health history should the nurse identify as a potential contributor to the patients headaches?
- A. The patient leads a sedentary lifestyle.
- B. The patient takes vitamin D and calcium supplements.
- C. The patient takes vasodilators for the treatment of angina.
- D. The patient has a pattern of weight loss followed by weight gain.
Correct Answer: C
Rationale: Vasodilators are known to trigger headaches. Sedentary lifestyle, supplements, or weight fluctuations are not directly linked to recurrent headaches.
A patient with increased ICP has a ventriculostomy for monitoring ICP. The nurses most recent assessment reveals that the patient is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication?
- A. Encephalitis
- B. CSF leak
- C. Meningitis
- D. Catheter occlusion
Correct Answer: C
Rationale: Nuchal rigidity and photophobia are signs of meningitis, a potential ventriculostomy complication. Encephalitis, CSF leak, and catheter occlusion present differently.
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.
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.