The client is a 43-year-old male who had a surgical removal of a benign tumor from the left hemisphere of his brain. The client's estimated blood loss (EBL) is 100 mL during surgical procedure. There were no complications. Vital signs remained stable throughout the procedure. The client will be admitted to the neurological intensive care unit for monitoring.

Answer and Explanation

The Correct Answer is []

Place the call light within the client's reach. The client has undergone surgery on the left hemisphere of the brain, which controls speech and motor function on the right side. This may lead to temporary weakness or speech difficulties, making it essential to ensure easy access to the call light for assistance.
Use a word board to help the client communicate. Damage to the left hemisphere can result in Broca aphasia, where the client has difficulty producing speech but can still understand language. A word board or communication aid allows the client to express needs effectively despite speech limitations.
Cerebral perfusion pressure. Monitoring cerebral perfusion pressure (CPP) is essential after brain surgery to ensure the brain is receiving adequate blood flow. Low CPP can lead to ischemia, while high CPP may indicate increased intracranial pressure (ICP), both of which can result in serious complications.
Level of consciousness. Assessing neurological status frequently helps detect early signs of deterioration, such as worsening intracranial pressure, cerebral edema, or postoperative bleeding. Changes in alertness, responsiveness, or confusion may indicate a need for urgent intervention.
Broca aphasia. Since the left hemisphere controls speech production, surgery in this area may cause Broca aphasia, where the client understands language but struggles to form words or complete sentences. The use of alternative communication methods is necessary to assist the client in expressing their needs.
Prepare the client to return to surgery. There is no indication of complications requiring an immediate return to the operating room. The estimated blood loss (100 mL) is minimal, and vital signs remained stable throughout the procedure.
Give ibuprofen as ordered. Ibuprofen (a nonsteroidal anti-inflammatory drug - NSAID) is contraindicated postoperatively because it can increase the risk of bleeding by inhibiting platelet function. Acetaminophen is typically preferred for pain control.
Elevate the head of the bed to 45 degrees. After brain surgery, the head of the bed should be elevated to 30 degrees, not 45 degrees. This optimizes cerebral venous drainage while preventing excessive intracranial pressure (ICP) changes that could impair perfusion.
White blood cell count. WBC count may be monitored for infection, but immediate concerns after brain surgery focus on neurological status and cerebral perfusion rather than infection unless symptoms of fever or worsening condition develop.
Pupil response. While pupil assessment is a key neurological parameter, it is more relevant for clients at risk of brain herniation or severe ICP elevation. In this case, monitoring level of consciousness and cerebral perfusion pressure takes priority.
Deep tendon reflexes. Reflex testing is not a primary concern after brain surgery unless there are signs of spinal cord involvement or a progressive neurological disorder. Monitoring motor function and speech ability is more relevant.
Myasthenia gravis. Myasthenia gravis is an autoimmune neuromuscular disorder that causes muscle weakness but is unrelated to brain tumor removal.
Cushing response. Cushing's response is a late sign of increased intracranial pressure (ICP), characterized by hypertension, bradycardia, and irregular respirations. The client has no signs of worsening ICP at this time.
Hydrocephalus. Hydrocephalus is excess cerebrospinal fluid (CSF) accumulation, which typically requires a shunt or external ventricular drain (EVD). There is no indication of CSF buildup in this client.

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Correct Answer is ["D","E","F"]

Explanation

A. Give the client 15 g of carbohydrates and retest the blood glucose in 15 minutes.
A blood glucose of 250 mg/dL is still high but does not require immediate carbohydrate administration. Carbohydrates are given in cases of hypoglycemia (blood glucose <70 mg/dL) or when transitioning from IV to subcutaneous insulin at lower glucose levels.
B. Bolus the client with 1 L of 3% sodium chloride solution.
The client’s sodium is already elevated (152 mEq/L), and hypertonic saline (3% NaCl) would worsen hypernatremia and increase the risk of neurological complications. Instead, hypotonic fluids (0.45% NaCl) are recommended once intravascular volume is stabilized.
C. Hold the insulin infusion.
HHS is managed with continuous insulin infusion to gradually reduce glucose levels. The blood glucose is still above the target range (250 mg/dL), so insulin should not be stopped prematurely to avoid a rebound in hyperglycemia.
D. Decrease the sodium concentration in the IV fluids from 0.9% to 0.45%.
Once circulatory volume is restored, fluids should be switched to 0.45% sodium chloride to correct hypernatremia and intracellular dehydration. This is a standard part of HHS treatment after initial fluid resuscitation.
E. Alert the provider of the current blood glucose level.
Glucose levels are improving but still high (250 mg/dL), requiring adjustments in fluid and insulin therapy. The provider should be informed to assess whether insulin titration or fluid changes are necessary.
F. Add 20 mEq of potassium chloride to the IV fluids.
Insulin therapy drives potassium into cells, leading to hypokalemia (K⁺ = 3.2 mEq/L), which can cause cardiac arrhythmias and muscle weakness. Potassium replacement is required to prevent complications and maintain normal levels.
G. Start a regular diet.
Clients with HHS require gradual rehydration and glucose control before transitioning to oral intake. A regular diet is not appropriate until the client is stable, glucose levels are consistently controlled, and IV therapy is discontinued.

A. Degree of pain using a 10 point scale. B. Pulse and blood pressure. C. Balance and coordination. D. Bilateral pupillary reaction to light.

Correct Answer is B

Explanation

A. Degree of pain using a 10-point scale. Pain assessment is important, but it is not the priority in an emergency trauma situation. Clients involved in motor vehicle collisions (MVCs) without a helmet are at high risk for life-threatening injuries, including hemorrhage and shock. The nurse must first assess vital signs to determine hemodynamic stability.
B. Pulse and blood pressure. The primary concern in trauma patients is circulation and perfusion. Assessing pulse and blood pressure helps determine if the client is experiencing shock, hemorrhage, or traumatic brain injury (TBI)-related autonomic dysfunction. In trauma resuscitation, the ABCs (Airway, Breathing, Circulation) guide assessment priorities, making circulatory status the first concern after ensuring airway patency.
C. Balance and coordination. A neurological assessment for balance and coordination is not a priority in a critically injured trauma patient. Severe injuries, including intracranial hemorrhage, cervical spine trauma, or internal bleeding, must be ruled out before assessing fine motor function.
D. Bilateral pupillary reaction to light. Pupillary response is part of a neurological assessment and is crucial in identifying traumatic brain injury. However, vital signs must be assessed first to determine hemodynamic stability, as untreated shock or hemorrhage can lead to rapid deterioration or death.

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Naxlex Comprehensive Predictor Exams

Exhibits Based on the client's laboratory values at 1600, which are appropriate nursing actions? Select all that apply.

Correct Answer is ["D","E","F"]

Explanation

A client who was involved in a motor vehicle collision while riding a motorcycle without wearing a helmet, is brought the emergency department (ED) by emergency medical services (EMS). Which assessment should the nurse obtain first?

Correct Answer is B

Explanation

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The nurse is administering low dose dopamine to a client who is in septic shock. Which physiologic parameter should the nurse use to evaluate a therapeutic response to the dopamine?

Exhibits Which are three goals of therapy for this client?

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A client, who is 4 hours postoperative laparotomy, has rapidly increasing abdominal distention with elevated pulse and respiratory rates. The client's skin is cool and pale, and there is no change in the blood pressure. Which intervention should the nurse implement immediately?