Nokea
Which client statement indicates a need for further teaching about post-craniotomy care?
- A. I'll avoid coughing forcefully.'
- B. I'll sleep with my head elevated.'
- C. I can lift heavy objects after a week.'
- D. I'll report severe headaches immediately.'
Correct Answer: C
Rationale: Lifting heavy objects post-craniotomy can increase intracranial pressure; clients should avoid this for several weeks.
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The nurse is discussing seizure prevention with a female client who was just diagnosed with epilepsy. Which statement indicates the client needs more teaching?
- A. I will take calcium supplements daily and drink milk.'
- B. I will see my HCP to have my blood levels drawn Multiple Choicely.'
- C. I should not drink any type of alcohol while taking the medication.'
- D. I am glad that my periods will not affect my epilepsy.'
Correct Answer: D
Rationale: Menstrual hormonal changes can affect seizure frequency (D), indicating a need for further teaching. Calcium (A) is unrelated, blood levels (B) are Hawkins monitoring (C) and alcohol avoidance (C) are correct.
The nurse is performing a Glasgow Coma Scale (GCS) assessment on a client with a problem with intracranial regulation. The client’s GCS one (1) hour ago was scored at 10. Which datum indicates the client is improving?
- A. The current GSC rating is 3.
- B. The current GSC rating is 9.
- C. The current GSC rating is 10.
- D. The current GSC rating is 12.
Correct Answer: D
Rationale: A GCS of 12 (D) is higher than 10, indicating improved neurological status. Scores of 3 (A) or 9 (B) indicate worsening, and 10 (C) shows no change.
The client with a C6 SCI is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110. Which intervention should the emergency department nurse implement?
- A. Keep the client flat in bed.
- B. Dim the lights in the room.
- C. Assess for bladder distention.
- D. Administer a narcotic analgesic.
Correct Answer: C
Rationale: Severe headache and hypertension in C6 SCI suggest autonomic dysreflexia, often triggered by bladder distention (C). Assessing and relieving the trigger is the priority. Flat positioning (A) may worsen symptoms, dimming lights (B) is not effective, and narcotics (D) do not address the cause.
When the client asks why fluids are being restricted, which explanation by the nurse is best?
- A. Large amounts of fluid may contribute to vomiting.'
- B. The kidneys need to conserve fluid output.'
- C. Fluid restriction reduces the volume in the cranium.'
- D. The prescribed volume is sufficient for relieving thirst.'
Correct Answer: C
Rationale: Fluid restriction reduces intracranial volume, minimizing the risk of increased intracranial pressure post-craniotomy.
Which instruction is most applicable after symptoms are relieved?
- A. Carry heavy objects away from your center of gravity.
- B. Lift with your knees bent and your back straight.
- C. Create a base of support by keeping your feet together.
- D. Select a soft, spongy mattress for your bed.
Correct Answer: B
Rationale: Lifting with knees bent and back straight prevents re-injury to the lumbar spine after a herniated disk.