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:
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.
Correct Answer is C
Explanation
Choice A rationale:
A balanced diet that includes fruits and vegetables is important for overall health, but it is not specifically related to the timing of sexual intercourse for conception.
Choice B rationale:
Using a lubricant during sexual intercourse can sometimes interfere with sperm motility and decrease the chances of conception.
Choice C rationale:
Having sexual intercourse 2 days following ovulation can increase the chances of fertilization since sperm can survive in the female reproductive tract for several days, and the egg is viable for a shorter period.
Choice D rationale:
While the type of underwear worn by the partner can influence testicular temperature, there is limited evidence to support the claim that tight-fitting underwear significantly affects fertility.
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