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.

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Correct Answer is C

Explanation

A. The oculocephalic reflex test should cause the eyes to move in the opposite direction to the head turn, indicating intact brainstem function.
B. Movement of the eyes in an upward direction upon neck flexion indicates an abnormal response, suggesting a lesion.
C. A lesion could result in abnormal eye movement, as the eyes should move opposite to head movement.
D. Eye movement in the downward direction during neck extension is not a normal response and suggests a brainstem issue.

A. Inability to recognize his family members B. Right hemiparesis C. Aphasia D. Difficulty reading

Correct Answer is A

Explanation

A. Damage to the right hemisphere, particularly the parietal and temporal lobes, can cause difficulty with recognition (prosopagnosia) and spatial awareness.
B. Right hemiparesis (weakness of the left side of the body) is common with left hemisphere damage, not right hemisphere damage.
C. Aphasia (language impairment) is typically associated with left hemisphere damage.
D. Difficulty reading (alexia) is more common with left hemisphere stroke, which controls language processing.

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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

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?

Correct Answer is C

Explanation

A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?

Correct Answer is A

Explanation

Which refractive error describes the vision of a patient for whom nearby objects are clear but objects at a distance are blurred?

Which medical condition places a patient at a higher risk for an embolic stroke?

A nurse is performing a home safety assessment for a client who has experienced a stroke. Which of the following findings are a safety hazards for the client?

A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility?

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?

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

A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?

Which intervention would the nurse implement to provide relief of the patient's discomfort when presenting to the clinic with a red, swollen, circumscribed, acutely, tender area near the eye and in the lid margin?