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What should the nurse suspect when hourly assessment of urine output on a patient postcraniotomy exhibits a urine output from a catheter of 1,500 mL for two consecutive hours?
- A. Cushing syndrome
- B. Syndrome of inappropriate antidiuretic hormone (SIADH)
- C. Adrenal crisis
- D. Diabetes insipidus
Correct Answer: D
Rationale: High urine output post-craniotomy suggests diabetes insipidus, common after brain surgery. Cushing syndrome and SIADH cause fluid retention, and adrenal crisis causes hypovolemia.
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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.
When caring for a patient with increased ICP the nurse knows the importance of monitoring for possible secondary complications, including syndrome of inappropriate antidiuretic hormone (SIADH). What nursing interventions would the nurse most likely initiate if the patient developed SIADH?
- A. Fluid restriction
- B. Transfusion of platelets
- C. Transfusion of fresh frozen plasma (FFP)
- D. Electrolyte restriction
Correct Answer: A
Rationale: SIADH causes fluid overload, requiring fluid restriction and electrolyte monitoring. Platelet or plasma transfusions and electrolyte restriction are not indicated.
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.
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.
While completing a health history on a patient who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state?
- A. Epileptic cry
- B. Confusion
- C. Urinary incontinence
- D. Body rigidity
Correct Answer: B
Rationale: Confusion is typical in the postictal state after a seizure. Epileptic cry, incontinence, and rigidity occur during the seizure, not afterward.