Which early symptoms in a focused assessment by the nurse may indicate the presence of a brain tumor?

Sudden unconsciousness, unresponsiveness, and apnea.

Increased temperature, blood pressure, heart rate, and respirations.

Changes in vision and personality, and headache upon awakening.

Fever, increased white blood cell count, and decreased appetite.

Answer and Explanation

The Correct Answer is C

Choice A reason: Sudden unconsciousness, unresponsiveness, and apnea are not typical symptoms of a brain tumor. They are more likely to indicate a stroke, seizure, or cardiac arrest.

Choice B reason: Increased temperature, blood pressure, heart rate, and respirations are not specific symptoms of a brain tumor. They are more likely to indicate an infection, inflammation, or stress.

Choice C reason: Changes in vision and personality, and headache upon awakening are common symptoms of a brain tumor. They are caused by the pressure of the tumor on the brain tissue and the cranial nerves.

Choice D reason: Fever, increased white blood cell count, and decreased appetite are not typical symptoms of a brain tumor. They are more likely to indicate a systemic infection or malignancy.

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Correct Answer is D

Explanation

Choice A reason: Assessment of arms and legs movement is an important part of the neurological assessment, but it is not the critical focus of care for a patient with a spinal cord injury at the cervical 5 vertebra. This level of injury affects the phrenic nerve, which controls the diaphragm and breathing. The patient may have difficulty breathing or require mechanical ventilation.

Choice B reason: Evaluation of knee jerk reflex is not the critical focus of care for a patient with a spinal cord injury at the cervical 5 vertebra. The knee jerk reflex is controlled by the spinal cord segments L2-L4, which are below the level of injury. The patient may have normal or exaggerated reflexes, depending on the extent of the spinal cord damage.

Choice C reason: Measurement of vital signs is a routine part of the nursing care, but it is not the critical focus of care for a patient with a spinal cord injury at the cervical 5 vertebra. The patient may have abnormal vital signs due to the injury, such as low blood pressure, slow heart rate, or irregular temperature. However, these are not as life-threatening as respiratory failure.

Choice D reason: Evaluation of respiratory status is the critical focus of care for a patient with a spinal cord injury at the cervical 5 vertebra. The patient is at high risk of respiratory compromise due to the impairment of the phrenic nerve and the diaphragm. The nurse should monitor the patient's oxygen saturation, respiratory rate, depth, and rhythm, and provide oxygen therapy or mechanical ventilation as needed. The nurse should also assess the patient for signs of respiratory infection, such as fever, cough, or sputum.

A. Maintain a flat lying position for 14 hours following the procedure. B. Muscular discomfort is expected after being in a curled position for a period of time. C. Resume oral intake immediately after the procedure. D. Mild pain is expected at the needle insertion site.

Correct Answer is A

Explanation

Choice A reason: Maintaining a flat lying position for 14 hours following the procedure is the highest priority teaching point for the patient who had a lumbar puncture. It helps to prevent cerebrospinal fluid leakage and post-lumbar puncture headache, which can be severe and debilitating.

Choice B reason: Muscular discomfort is expected after being in a curled position for a period of time, but it is not the highest priority teaching point for the patient who had a lumbar puncture. It is a common and mild side effect that can be relieved by analgesics, massage, or heat therapy.

Choice C reason: Resuming oral intake immediately after the procedure is not a priority teaching point for the patient who had a lumbar puncture. It is not contraindicated, but it is not essential either. The patient should drink plenty of fluids to replenish the cerebrospinal fluid and prevent dehydration.

Choice D reason: Mild pain is expected at the needle insertion site, but it is not the highest priority teaching point for the patient who had a lumbar puncture. It is a common and mild side effect that can be relieved by analgesics, ice packs, or dressing.

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Which early symptoms in a focused assessment by the nurse may indicate the presence of a brain tumor?

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Correct Answer is A

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