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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 D

Explanation

Choice A rationale:

Asking why the client enjoys gambling doesn't address the underlying issues of gambling disorder.

Choice B rationale:

Instructing the client to apologize to their family is judgmental and not therapeutic.

Choice C rationale:

Assuming the family's emotions and feelings is not appropriate and may not be accurate.

Choice D rationale:

Asking about the client's first experience with gambling can help uncover triggers and patterns related to the disorder, which can be useful for treatment.

A. A 64-year-old client who is taking estrogen supplements B. A 70-year-old client who has COPD C. A 28-year-old client who has a left arm fracture D. A 53-year-old client who has a thin build

Correct Answer is B

Explanation

A. Taking estrogen supplements does not significantly increase infection risk in clients receiving chemotherapy.
B. A 70-year-old client with chronic obstructive pulmonary disease (COPD) is at greatest risk for infection because advanced age and chronic lung disease both impair immune function and increase susceptibility to respiratory infections, especially during chemotherapy.
C. A left arm fracture may increase local infection risk, but it does not pose as high a systemic infection risk as COPD in an older adult.
D. Having a thin build does not inherently increase infection risk in the context of chemotherapy.

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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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