Nokea
The nurse is caring for a patient with permanent neurologic impairments resulting from a traumatic head injury. When working with this patient and family, what mutual goal should be prioritized?
- A. Achieve as high a level of function as possible.
- B. Enhance the quantity of the patients life.
- C. Teach the family proper care of the patient.
- D. Provide community assistance.
Correct Answer: A
Rationale: Maximizing function is the primary goal for neurologic impairment, encompassing quality of life and family/community involvement. Quantity of life is less relevant.
You may also like to solve these questions
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.
A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the patients plan of care?
- A. Monitoring of pulse oximetry
- B. Administration of a low-protein diet
- C. Administration of thorough oral hygiene
- D. Fluid restriction as ordered
Correct Answer: C
Rationale: Phenytoin can cause gingival hyperplasia, making thorough oral hygiene essential. Pulse oximetry, low-protein diet, and fluid restriction are not related to phenytoin's adverse effects.
The nurse is providing care for a patient who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the patient has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following?
- A. The ability of the patient to follow instructions during the seizure.
- B. The success or failure of the care team to physically restrain the patient.
- C. The patients ability to explain his seizure during the postictal period.
- D. The patients activities immediately prior to the seizure.
Correct Answer: D
Rationale: Documenting pre-seizure activities helps identify triggers. Patients cannot follow instructions or explain seizures during or postictally, and restraint is contraindicated.
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 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.