The nurse is assessing a client with a brain tumor who is prescribed dexamethasone.
Which assessment change creates the highest priority situation?
The client no longer remembers their name.
The client has gained weight.
The client complains of insomnia.
Blood glucose level of 350 mg/dL...
The Correct Answer is A
Dexamethasone is a potent corticosteroid used to reduce cerebral edema in brain tumor patients. Prioritizing care requires identifying life-threatening neurological changes or severe medication side effects, applying knowledge of intracranial pressure, glucose metabolism, and the hierarchy of clinical needs.
Choice A rationale
Acute loss of orientation to self indicates a significant decline in neurological status or increased intracranial pressure. This is a medical emergency requiring immediate intervention to prevent brain herniation, outweighing stable physical side effects of steroid therapy.
Choice B rationale
Weight gain is a common side effect of long-term dexamethasone use due to fluid retention and increased appetite. While it requires monitoring, it is an expected systemic effect and does not represent an immediate life-threatening crisis.
Choice C rationale
Insomnia is a known side effect of corticosteroids because they can interfere with the circadian rhythm and stimulate the central nervous system. It affects the client's comfort but does not indicate immediate physiological or neurological compromise.
Choice D rationale
Glucocorticoids cause hyperglycemia; 350 mg/dL is high compared to the normal fasting range of 70 to 100 mg/dL. While it requires insulin or dosage adjustment, it is less urgent than an acute neurological deficit..
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This scenario requires understanding of integumentary integrity and burn wound management. Knowledge of infection prevention and moist wound healing principles is essential. Partial-thickness burns involve the epidermis and dermis, necessitating protection of the newly exposed, vulnerable basement membrane to facilitate re-epithelialization.
Choice A rationale
. Antimicrobials prevent colonization of exposed dermis while nonadherent dressings maintain a moist environment. This facilitates cellular migration and prevents further trauma during future dressing changes. Protecting the bed from environmental pathogens is critical for healing and preventing secondary infection.
Choice B rationale
. Air exposure causes desiccation of the wound bed, which leads to cell death and delayed healing. Dry environments promote eschar formation, increasing the risk of scarring. Maintaining a moist interface is the gold standard for promoting rapid dermal repair.
Choice C rationale
. Dry gauze adheres to the wound exudate and causes significant tissue damage during removal. Tight application can also impair local capillary circulation, leading to ischemia. Dressings should be applied loosely enough to ensure adequate perfusion to the healing tissue.
Choice D rationale
. Intact blisters serve as a biological dressing, protecting the underlying dermis from infection. Removing them prematurely exposes the wound bed unnecessarily to the external environment. They should only be debrided if they are large enough to impede joint movement.
Correct Answer is ["2300"]
Explanation
Step 1 is (25,000 units ÷ 250 mL) × 23 mL = 2,300 units per hour.
Final calculated answer is 2,300.
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