A nurse is assessing a client who is 4 hr postoperative following a craniotomy for the treatment of a benign brain tumor. Which of the following findings should the nurse identify as the priority?
15 mL of drainage in Hemovac
Periorbital ecchymosis
Nonreactive pupils
Hgb 11 g/dL
The Correct Answer is C
Choice A rationale:
Drainage in the Hemovac is an expected finding postoperatively and is not as urgent as nonreactive pupils.
Choice B rationale:
Periorbital ecchymosis (bruising around the eyes) is not uncommon after a craniotomy and is not as urgent as nonreactive pupils.
Choice C rationale:
Nonreactive pupils can indicate a neurological emergency, such as increased intracranial pressure or potential damage to the cranial nerves. This finding requires immediate attention to prevent further complications.
Choice D rationale:
Hemoglobin level of 11 g/dL is within a normal range and is not a priority concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
During the manic phase of bipolar disorder, sleep disturbances are common. Setting a goal for the client to achieve an appropriate amount of sleep can help stabilize their mood and reduce the intensity of manic symptoms.
Choice B rationale:
A weight loss goal might be more appropriate during the depressive phase, as manic episodes are often associated with increased energy and decreased appetite.
Choice C rationale:
Increased urine specific gravity is not a specific goal for managing the manic phase of bipolar disorder.
Choice D rationale:
Giving personal gifts to other clients might be a manifestation of the client's manic behavior and is not a goal to strive for.
Correct Answer is C
Explanation
Choice A rationale:
Drowsiness is not a common side effect of phentermine/topiramate.
Choice B rationale:
An irregular menstrual cycle is not a common side effect of phentermine/topiramate.
Choice C rationale:
Phentermine/topiramate is a medication used to assist with weight loss. Topiramate, one of the components of this medication, can increase the risk of birth defects if taken during pregnancy. Therefore, it is important for women of childbearing age to avoid becoming pregnant while on this medication and to use effective contraception.
Choice D rationale:
Loose stools are a potential side effect of phentermine/topiramate, but this statement does not necessarily indicate an understanding of the medication's purpose and precautions.
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