Which intervention would the nurse implement as the priority when providing care for a patient with a ventriculostomy to measure increased intra-cranial pressure (ICP) caused by a brain tumor?

Beware of changes in ICP related to leaking cerebrospinal fluid (CSF)

Maintain hyper-oxygenation through use of a ventilator

Use strict aseptic technique with all procedural dressing changes

Administer IV mannitol (Osmitrol)

Answer and Explanation

The Correct Answer is C

A.   Monitoring for CSF leakage is crucial to avoid infection and to maintain ICP accuracy.
B.   Hyper-oxygenation may be used in certain cases but is not the priority.
C.   Aseptic technique for all procedures and dressing changes is critical to prevent infection.
D.   Administering IV mannitol can be important, but aseptic technique is the priority to prevent infection.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. The BP must be lower than 180/105 mm Hg to receive fibrinolytic agents, not 130/70 mm Hg.
B. Elevated BPs are common immediately after a stroke, but drug therapy to lower BP is not initiated unless it reaches high levels (typically > 220/120 mm Hg).
C. A lower BP does not act as a protective response; maintaining a higher BP can be necessary initially after a stroke to ensure adequate cerebral perfusion.

D. If BP is 220/120 mm Hg or higher after ischemic stroke, aggressive antihypertensive therapy is initiated to reduce the risk of hemorrhagic transformation and other complications.

A. Encourage the client to use his right hand when feeding himself. B. Provide a nonskid mat to alleviate plate movement. C. Encourage the use of the wide grip utensils. D. Remind the client to look for food on the left side of the tray.

Correct Answer is D

Explanation

A. Encourage the client to use his right hand when feeding himself: This would be inappropriate since the patient likely has impaired vision in the left field.
B. Provide a nonskid mat to alleviate plate movement: This may be helpful for safety, but it does not address the visual deficit.
C. Encourage the use of wide grip utensils: This may assist with fine motor skills but doesn't directly help with vision problems.
D. Remind the client to look for food on the left side of the tray: This is important because homonymous hemianopsia affects one visual field, and the nurse should encourage the patient to scan their environment to locate food.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which intervention would the nurse implement as the priority when providing care for a patient with a ventriculostomy to measure increased intra-cranial pressure (ICP) caused by a brain tumor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement is accurate about the recommendations for BP management after an ischemic stroke?

Correct Answer is D

Explanation

A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

If blood flow to the brain is interrupted, how quickly does cellular death occur?

When explaining normal intracranial pressure (ICP) balance to the patient's family, which three components would the nurse include?

A nurse is taking care of a client who has sustained a neurologic injury with increased intracranial pressure and decreased cerebral perfusion. Which of the following will keep cerebral perfusion pressure constant?

For the patient who wears contact lenses, which intervention would the nurse teach the patient when diagnoses with bacterial conjunctivitis?

A nurse is teaching an older adult client who has diabetes mellitus about preventing the long- term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?

After performing an assessment of the oculocephalic reflex, the nurse suspects that the patient has an intracranial lesion. Which patient behavior supports the nurse's assessment findings?

Which initial clinical manifestation would a patient report with a retinal detachment?