Nokea
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.
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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.
A patient is recovering from intracranial surgery performed approximately 24 hours ago and is complaining of a headache that the patient rates at 8 on a 10-point pain scale. What nursing action is most appropriate?
- A. Administer morphine sulfate as ordered.
- B. Reposition the patient in a prone position.
- C. Apply a hot pack to the patients scalp.
- D. Implement distraction techniques.
Correct Answer: A
Rationale: Severe post-craniotomy headache warrants morphine administration. Prone positioning increases ICP, hot packs may worsen pain, and distraction is inadequate for severe pain.
A patient is recovering from intracranial surgery that was performed using the transsphenoidal approach. The nurse should be aware that the patient may have required surgery on what neurologic structure?
- A. Cerebellum
- B. Hypothalamus
- C. Pituitary gland
- D. Pineal gland
Correct Answer: C
Rationale: The transsphenoidal approach accesses the pituitary gland via the nasal cavity. The cerebellum, hypothalamus, and pineal gland are not reached this way.
The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of ineffective cerebral tissue perfusion. What would be an expected outcome that the nurse would document for this diagnosis?
- A. Copes with sensory deprivation.
- B. Registers normal body temperature.
- C. Pays attention to grooming.
- D. Obeys commands with appropriate motor responses.
Correct Answer: D
Rationale: Obeying commands with appropriate motor responses indicates improved cerebral perfusion. Other outcomes relate to sensory perception, thermoregulation, or body image, not perfusion.
A hospital patient has experienced a seizure. In the immediate recovery period, what action best protects the patients safety?
- A. Place the patient in a side-lying position.
- B. Pad the patients bed rails.
- C. Administer antianxiety medications as ordered.
- D. Reassure the patient and family members.
Correct Answer: B
Rationale: A side-lying position prevents aspiration of secretions post-seizure. Padding rails, antianxiety drugs, or reassurance are secondary to airway safety.