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The nurse is caring for the client with a leaking cerebral aneurysm. What is the earliest sign that would indicate to the nurse that increased ICP may be developing?
- A. Change in pupil size and reaction
- B. Sudden drop in the blood pressure
- C. Experiencing diminished sensation
- D. Change in the level of consciousness
Correct Answer: D
Rationale: Pupillary changes may occur with ICP as it progresses, but they are not an early sign of developing ICP. A drop in BP is not directly associated with neurological deterioration. A BP with a wide pulse pressure is a late sign of increased ICP. Diminished sensation may occur with increased ICP, but it is not the earliest sign. A change in the level of consciousness is the first sign of neurological deterioration and is often associated with the development of increased ICP.
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When documenting a seizure, which information is most important to include initially?
- A. The time the seizure started
- B. The duration of the seizure
- C. The client's mood just before the seizure
- D. The client's comments after the seizure
Correct Answer: A
Rationale: Documenting the time the seizure started is critical for tracking seizure patterns and guiding treatment.
The client is being discharged following a transsphenoidal hypophysectomy. Which discharge instructions should the nurse teach the client? Select all that apply.
- A. Sleep with the head of the bed elevated.
- B. Keep a humidifier in the room.
- C. Use caution when performing oral care.
- D. Stay on a full liquid diet until seen by the HCP.
- E. Notify the HCP if developing a cold or fever.
Correct Answer: A,C,E
Rationale: Elevating the HOB (A) reduces ICP, cautious oral care (C) prevents surgical site disruption, and reporting infections (E) is critical due to infection risk. Humidifiers (B) are not standard, and a liquid diet (D) is unnecessary unless specified.
The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply.
- A. Position the client to prevent shoulder adduction.
- B. Turn and reposition the client every shift.
- C. Encourage the client to move the affected side.
- D. Perform quadriceps exercises three (3) times a day.
- E. Instruct the client to hold the fingers in a fist.
Correct Answer: A,C,D
Rationale: For a right-sided CVA, the left side is affected. Positioning to prevent shoulder adduction (A) supports the weak left arm to prevent contractures. Encouraging movement of the affected side (C) promotes neuroplasticity and recovery. Quadriceps exercises (D) strengthen the affected leg. Turning every shift (B) is too infrequent; every 2 hours is standard to prevent pressure ulcers. Instructing to hold fingers in a fist (E) risks contractures and is not therapeutic.
A hospitalized client diagnosed with seizures has a vagus nerve stimulation (VNS) device implanted. The nurse determines that the VNS is working properly when making which observation?
- A. It stimulated a heartbeat when bradycardia occurred during a seizure.
- B. It defibrillated a lethal rhythm that occurred during the client’s seizure.
- C. The client activates the VNS device to stop a seizure from occurring.
- D. The client activates the device at seizure onset to prevent aspiration.
Correct Answer: C
Rationale: A VNS device does not stimulate the heart to beat as a pacemaker. A VNS device does not defibrillate the heart as an implantable cardioverter/defibrillator does. A VNS is a medical device that is implanted in the chest and stimulates the vagus nerve to control seizures unresponsive to medical treatment. Clients who experience auras before a seizure use a magnet to activate the VNS to stop the seizure. The device does not have an effect on the airway or secretions.
Which discharge teaching is essential for a client with a spinal cord injury to prevent respiratory complications?
- A. Perform deep breathing exercises daily.
- B. Avoid outdoor activities.
- C. Limit fluid intake to reduce secretions.
- D. Sleep in a prone position.
Correct Answer: A
Rationale: Deep breathing exercises help prevent atelectasis and pneumonia in clients with spinal cord injuries.