Nokea
Which preoperative assessment is most important to document as a basis for postoperative comparison?
- A. Motor strength in all extremities
- B. Sodium and potassium laboratory values
- C. Pulses in lower extremities
- D. Glucometer blood glucose levels
Correct Answer: A
Rationale: Motor strength assessment provides a baseline to detect postoperative neurological deficits from brain tumor surgery.
You may also like to solve these questions
The client diagnosed with breast cancer has developed metastasis to the brain. Which prophylactic measure should the nurse implement?
- A. Institute aspiration precautions.
- B. Refer the client to Reach to Recovery.
- C. Initiate seizure precautions.
- D. Teach the client about mastectomy care.
Correct Answer: C
Rationale: Brain metastases increase seizure risk, so seizure precautions (C) are appropriate. Aspiration precautions (A) are unrelated, Reach to Recovery (B) supports breast cancer recovery, and mastectomy care (D) is not relevant to brain metastases.
Which assessment data would make the nurse suspect that the client with a C7 spinal cord injury is experiencing autonomic dysreflexia?
- A. Abnormal diaphoresis.
- B. A severe throbbing headache.
- C. Sudden loss of motor function.
- D. Spastic skeletal muscle movement.
Correct Answer: B
Rationale: Autonomic dysreflexia in SCI causes severe headache (B) due to hypertensive crisis from a trigger like bladder distention. Diaphoresis (A) is secondary, motor loss (C) is expected, and spasticity (D) is chronic.
The nurse is caring for clients on a medical-surgical floor. Which clients should be assessed first?
- A. The 65-year-old client diagnosed with seizures who is complaining of a headache that is a '2' on a 1-to-10 scale.
- B. The 24-year-old client diagnosed with a T10 spinal cord injury who cannot move his toes.
- C. The 58-year-old client diagnosed with Parkinson’s disease who is crying and worried about her facial appearance.
- D. The 62-year-old client diagnosed with a cerebrovascular accident who has a resolving left hemiparesis.
Correct Answer: B
Rationale: Inability to move toes in a T10 SCI (B) may indicate neurological deterioration or edema, requiring immediate assessment. Mild headache (A), emotional distress (C), and resolving hemiparesis (D) are less urgent.
The nurse is caring for the client experiencing Guillain-Barré syndrome (GBS). It is most important for the nurse to monitor the client for which complication?
- A. Autonomic dysreflexia
- B. Septic emboli
- C. Cardiac dysrhythmias
- D. Respiratory failure
Correct Answer: D
Rationale: The client with SCI, not GBS, should be monitored for autonomic dysreflexia. The client who has bacterial meningitis should be monitored for septic emboli. Although the client with GBS should be monitored for cardiac dysrhythmias, it is most important to monitor for respiratory failure. It is most important for the nurse to monitor for respiratory failure. Ascending paralysis that occurs in GBS can affect the innervations of the muscles used in respiration, leading to respiratory failure.
The 29-year-old client is admitted to the medical floor diagnosed with meningitis. Which assessment by the nurse has priority?
- A. Assess lung sounds.
- B. Assess the six cardinal fields of gaze.
- C. Assess apical pulse.
- D. Assess level of consciousness.
Correct Answer: D
Rationale: Level of consciousness (D) is the priority assessment in meningitis, as it indicates neurological status and potential complications like increased ICP. Lung sounds (A), eye movements (B), and pulse (C) are secondary.