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 B
Explanation
Choice A rationale:
Diarrhea is not commonly associated with pramipexole use.
Choice B rationale:
Drowsiness is a common adverse effect of pramipexole and can impair the client's ability to perform tasks that require alertness.
Choice C rationale:
Tachypnea (rapid breathing) is not typically associated with pramipexole use.
Choice D rationale:
Bradycardia (slow heart rate) is not a common adverse effect of pramipexole.
Correct Answer is C
Explanation
Choice A rationale:
Wearing splints over affected joints while sleeping is a strategy to prevent contractures, which are common in ALS.
Choice B rationale:
Dexamethasone is not used to treat muscle atrophy in ALS.
Choice C rationale:
As ALS progresses, clients may lose the ability to control their respiratory muscles, and a machine such as a ventilator may be required to assist with breathing.
Choice D rationale:
Nutrition through a central venous access device is not a standard intervention for ALS, as the focus is on preserving the client's ability to eat and swallow for as long as possible.
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