Nokea
While assessing the patient at the beginning of the shift, the nurse inspects a surgical dressing covering the operative site after the patients cervical diskectomy. The nurse notes that the drainage is 75% saturated with serosanguineous discharge. What is the nurses most appropriate action?
- A. Page the physician and report this sign of infection.
- B. Reinforce the dressing and reassess in 1 to 2 hours.
- C. Reposition the patient to prevent further hemorrhage.
- D. Inform the surgeon of the possibility of a dural leak.
Correct Answer: D
Rationale: Serosanguineous drainage suggests a dural leak, a serious complication requiring surgical notification. It is not a direct sign of infection, and repositioning or reinforcing the dressing delays critical intervention.
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The nurse is caring for a patient who is scheduled for a cervical discectomy the following day. During health education, the patient should be made aware of what potential complications?
- A. Vertebral fracture
- B. Hematoma at the surgical site
- C. Scoliosis
- D. Renal trauma
Correct Answer: B
Rationale: Hematoma at the surgical site is a key complication of cervical diskectomy, risking cord compression. Fractures, scoliosis, or renal trauma are not typical risks.
A nurse is assessing a patient with an acoustic neuroma who has been recently admitted to an oncology unit. What symptoms is the nurse likely to find during the initial assessment?
- A. Loss of hearing, tinnitus, and vertigo
- B. Loss of vision, change in mental status, and hyperthermia
- C. Loss of hearing, increased sodium retention, and hypertension
- D. Loss of vision, headache, and tachycardia
Correct Answer: A
Rationale: Acoustic neuroma, a tumor of the eighth cranial nerve, affects hearing and balance, causing hearing loss, tinnitus, and vertigo. Vision loss, sodium retention, or tachycardia are not typical symptoms.
A patient diagnosed with a pituitary adenoma has arrived on the neurologic unit. When planning the patients care, the nurse should be aware that the effects of the tumor will primarily depend on what variable?
- A. Whether the tumor utilizes aerobic or anaerobic respiration
- B. The specific hormones secreted by the tumor
- C. The patients pre-existing health status
- D. Whether the tumor is primary or the result of metastasis
Correct Answer: B
Rationale: Pituitary adenoma effects depend on the hormones it secretes, impacting bodily functions. Respiration type, health status, or tumor origin are less determinative.
A family member of a patient diagnosed with Huntington disease calls you at the clinic. She is requesting help from the Huntingtons Disease Society of America. What kind of help can this patient and family receive from this organization? Select all that apply.
- A. Information about this disease
- B. Referrals
- C. Public education
- D. Individual assessments
- E. Appraisals of research studies
Correct Answer: A,B,C
Rationale: The Huntington's Disease Society of America provides information, referrals, and public education. It does not offer individual assessments or research appraisals.
A nurse is planning discharge education for a patient who underwent a cervical diskectomy. What strategies would the nurse assess that would aid in planning discharge teaching?
- A. Care of the cervical collar
- B. Technique for performing neck ROM exercises
- C. Home assessment of ABGs
- D. Techniques for restoring nerve function
Correct Answer: A
Rationale: Cervical collar care is essential for post-diskectomy recovery to maintain alignment. ROM exercises, ABG assessment, and nerve restoration are not appropriate.