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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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Maternal hemoglobin and hematocrit levels are important indicators of the mother's health but are not direct indicators of fetal well-being.

Choice B rationale:

A Coombs test is performed on newborns to assess for hemolytic disease, not to monitor fetal well-being.

Choice C rationale:

A biophysical profile assesses multiple parameters of fetal well-being, including fetal heart rate, fetal movement, fetal breathing, amniotic fluid volume, and fetal tone.

Choice D rationale:

An alpha-fetoprotein test is a screening test for neural tube defects and chromosomal abnormalities but is not typically used to monitor fetal well-being in hypertensive pregnancies.

A. "Disguise exit doors in his home with posters." B. "Weigh the client once per month." C. "Keep the lights in his room off at night." D. "Offer him several food choices prior to meal times."

Correct Answer is A

Explanation

Choice A rationale:

People with dementia may become disoriented and attempt to leave their homes. Disguising exit doors with posters or camouflage can help prevent wandering and promote safety.

Choice B rationale:

Weighing the client once per month is not directly related to dementia care and safety.

Choice C rationale:

Keeping lights on at night can help prevent falls and confusion in people with dementia.

Choice D rationale:

Offering several food choices prior to meal times can be overwhelming for a person with dementia. A simpler approach may be more appropriate.

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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?

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