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:
Clients with Parkinson's disease often have motor difficulties and slowed movements. Allowing extra time for activities of daily living (ADLs) can help them maintain independence and reduce frustration.
Choice B rationale:
Weight gain is not a common manifestation of Parkinson's disease or a primary concern in its management.
Choice C rationale:
Instructing the client to look down at the feet when walking is not accurate advice for Parkinson's disease. It's important to maintain an upright posture and look ahead to improve balance and gait.
Choice D rationale:
A low-protein diet is not generally recommended for clients with Parkinson's disease, as protein can affect the absorption of levodopa, a common medication used in its management.
Correct Answer is B
Explanation
Choice A rationale:
Terbutaline is a medication used to inhibit uterine contractions and is not directly related to managing coarctation of the aorta.
Choice B rationale:
Coarctation of the aorta is a congenital heart defect characterized by narrowing of the aorta, which can lead to increased pressure and decreased blood flow to the lower part of the body. During labor, epidural anesthesia is often recommended for clients with coarctation of the aorta to reduce stress and pain, as well as to maintain stable blood pressure.
Choice C rationale:
Placing a client with coarctation of the aorta in a supine position during labor can worsen the obstruction of blood flow and is contraindicated. Left lateral positioning or other positions that enhance venous return are preferred.
Choice D rationale:
There is no established increased risk of preeclampsia in clients with coarctation of the aorta.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.