A client required endotracheal intubation with sedation due to being in status epilepticus.
An electroencephalogram (EEG) monitor is prescribed by the physician.
The client's family member asks, "if he's resting now, why does he need that monitor too?" The nurse instructs the family member that the EEG:

Helps determine if there has been bleeding to brain tissue.

Checks for adequate oxygen intake by cerebral tissue.

Will assess brain waves to see if seizure activity is still occurring.

Answer and Explanation

The Correct Answer is C

Choice A rationale

While bleeding could indicate trauma, EEG does not detect blood presence or volume but instead evaluates electrical brain activity indicative of neuronal function.

Choice B rationale

Cerebral oxygen intake assessment requires pulse oximetry or arterial blood gas analysis rather than EEG, which monitors electrical signals, not oxygenation status.

Choice C rationale

EEG identifies abnormal brain wave patterns suggesting ongoing seizure activity, even in sedated patients, aiding in targeted interventions and preventing potential complications.

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Correct Answer is B

Explanation

Choice A rationale

Applying pressure to prevent drainage could force cerebrospinal fluid (CSF) back into the cranial cavity, increasing infection risk and intracranial pressure, potentially worsening brain injury. CSF leakage requires non-obstructive handling.

Choice B rationale

Allowing fluid to drain onto gauze prevents build-up of intracranial pressure while assessing for halo sign, indicating CSF leakage. Yellow staining reflects glucose presence in CSF, confirming dura mater damage.

Choice C rationale

Intravenous fluids manage hypovolemia but are not prioritized for trauma patient brain injuries. Replacing lost CSF requires specific medical intervention rather than fluid volume adjustments alone.

Choice D rationale

Antibiotics treat infections but are not first priority for confirmed CSF leakage, which demands careful monitoring of drainage to prevent neurological damage. Post-intervention antibiotics may be necessary.

A. Hold the feeding if the client has soft brown stools and is passing flatus. B. Dilute each medication with 5% dextrose in water (D5W) and flush with at least 30 mL. C. Discuss the order with the prescriber if the client's abdomen is distended with hypoactive bowel sounds and RLQ tenderness. D. Check for residual enteral formula prior to administration.

Correct Answer is C

Explanation

Choice A rationale

Soft stools and flatus indicate proper gastrointestinal function, suggesting tolerance to feeding. With no adverse symptoms, it is not scientifically valid to hold enteral feeding based on these findings alone.

Choice B rationale

Diluting medications with D5W and flushing ensures patency but does not address potential complications like abdominal distention or bowel sounds. RLQ tenderness must first be evaluated for safety.

Choice C rationale

Abdomen distention with hypoactive bowel sounds and RLQ tenderness suggests possible ileus or bowel obstruction. Discussing this condition with the prescriber ensures safe feeding practices and prevents worsening complications.

Choice D rationale

Residual formula checks are relevant for gastric, not jejunostomy, feeding. Scientific practice discourages assessing residual in jejunostomy feeding as the tube bypasses the stomach.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a trauma patient with a suspected brain injury and Battle's Sign.The nurse notices a yellow stain around fluid dripping from the patient's ear.The nurse's priority intervention will be as follows:

Correct Answer is B

Explanation

A client with a severe stroke has been prescribed enteral feedings via a jejunostomy tube.For safe administration, the nurse should:

Correct Answer is C

Explanation

A client's daughter asks the nurse for assistance in communicating with her mother who has sensorineural hearing loss.Which point is appropriate for the nurse to teach?

A nurse is caring for a client who has had repeated instances of cystitis.When considering possible ascending progression of the infection, the client should be taught to monitor for:

A nurse is caring for a patient with a spinal cord injury who is about to be transferred to a wheelchair for physical therapy.The patient complains of feeling dizzy and is diaphoretic.What would be the priority nursing action?

A client presents to the emergency department actively having seizure activity.The paramedics report the client has a history of epilepsy but her family doesn't know the names of her current medications.The priority for this patient is:

A nurse is caring for a patient in the ICU with a diagnosis of an acute closed head injury whose intracranial pressure (ICP) is 25 mmHg.What is the priority action by the nurse?