Nokea
The nurse plans to show the spouse of the client with a suspected epidural hematoma where the epidural hematoma occurs in the brain. Which illustration should the nurse select when teaching the client’s spouse?
- A. Illustration A
- B. Illustration B
- C. Illustration C
- D. Illustration D
Correct Answer: B
Rationale: This illustration shows a subdural hematoma, which occurs below the dura. This illustration shows an epidural hematoma, which occurs between the skull and the dura. This illustration shows normal brain structures. An intracerebral hematoma occurs within the brain tissue and can result in brain herniation as shown in this illustration.
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Because carbamazepine (Tegretol) can cause liver dysfunction, the client's discharge plan should include instructions to report which symptom?
- A. Unusual bleeding
- B. Yellowing of the skin
- C. Cloudy urine
- D. Mottled skin
Correct Answer: B
Rationale: Yellowing of the skin (jaundice) indicates potential liver dysfunction, a known side effect of carbamazepine.
The client diagnosed with a brain tumor has a diminished gag response and weakness on the left side of the body. Which intervention should the nurse implement?
- A. Make the client NPO until seen by the health-care provider.
- B. Position the client in low Fowler’s position for all meals.
- C. Place the client on a mechanically ground diet.
- D. Teach the client to direct food and fluid toward the right side.
Correct Answer: A
Rationale: A diminished gag reflex increases aspiration risk, so making the client NPO (A) is safest until swallowing is evaluated. Low Fowler’s (B) increases aspiration risk, a ground diet (C) is premature, and directing food (D) requires intact swallowing.
The nurse is caring for the older adult client with normal pressure hydrocephalus (NPH). Which treatment measure should the nurse anticipate?
- A. Carotid endarterectomy
- B. Ventriculoperitoneal shunt
- C. Insertion of a lumbar drain
- D. Anticonvulsant medications
Correct Answer: B
Rationale: A carotid endarterectomy involves removal of plaque from the carotid artery. NPH is treated with the placement of a permanent shunt in a lateral ventricle of the brain to the peritoneal cavity. The excess CSF drains into the peritoneal cavity. A lumbar drain can be used to remove CSF with disorders that increase CSF in the subarachnoid space in the lumbar area; this does not remain permanently. Anticonvulsant medications are used to treat seizures.
The nurse is enjoying a day at the lake and witnesses a water skier hit the boat ramp. The water skier is in the water not responding to verbal stimuli. The nurse is the first health-care provider to respond to the accident. Which intervention should be implemented first?
- A. Assess the client's level of consciousness.
- B. Organize onlookers to remove the client from the lake.
- C. Perform a head-to-toe assessment to determine injuries.
- D. Stabilize the client's cervical spine.
Correct Answer: D
Rationale: In trauma with potential head or neck injury, stabilizing the cervical spine (D) is the first priority to prevent spinal cord injury during movement. Assessing consciousness (A), organizing removal (B), or performing a full assessment (C) follows.
When the nurse describes the myelogram procedure to the client, which statement is most accurate?
- A. Part of the test involves a lumbar puncture.'
- B. You will be asked to change positions frequently.'
- C. Dye is instilled into a vein in your arm.'
- D. Light anesthesia is administered during the test.'
Correct Answer: A
Rationale: A myelogram involves a lumbar puncture to inject contrast dye into the spinal canal for imaging.