Nokea
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.
You may also like to solve these questions
The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of ineffective cerebral tissue perfusion. What would be an expected outcome that the nurse would document for this diagnosis?
- A. Copes with sensory deprivation.
- B. Registers normal body temperature.
- C. Pays attention to grooming.
- D. Obeys commands with appropriate motor responses.
Correct Answer: D
Rationale: Obeying commands with appropriate motor responses indicates improved cerebral perfusion. Other outcomes relate to sensory perception, thermoregulation, or body image, not perfusion.
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.
A school nurse is called to the playground where a 6-year-old girl has been found unresponsive and staring into space, according to the playground supervisor. How would the nurse document the girls activity in her chart at school?
- A. Generalized seizure
- B. Absence seizure
- C. Focal seizure
- D. Unclassified seizure
Correct Answer: B
Rationale: Staring and unresponsiveness characterize an absence seizure, common in children. Generalized and focal seizures involve motor activity, and unclassified seizures lack clear patterns.
A patient has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the patients ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following?
- A. Hemiplegia
- B. Dry mucous membranes
- C. Signs of internal bleeding
- D. Loss of brain stem reflexes
Correct Answer: D
Rationale: Loss of brain stem reflexes (e.g., pupillary, corneal) signals impending death in severe head injury. Hemiplegia, dry membranes, and bleeding are not specific to this outcome.
An adult patient has sought care for the treatment of headaches that have become increasingly severe and frequent over the past several months. Which of the following questions addresses potential etiological factors? Select all that apply.
- A. Are you exposed to any toxins or chemicals at work?
- B. How would you describe your ability to cope with stress?
- C. What medications are you currently taking?
- D. When was the last time you were hospitalized?
- E. Does anyone else in your family struggle with headaches?
Correct Answer: A,B,C, E
Rationale: Headaches are multifactorial; toxins, stress, medications, and family history contribute. Hospitalization is not a direct etiological factor.