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 ["A","B","E"]

Explanation

A. Dim lighting installed throughout the house: Poor lighting increases the risk of falls and accidents, especially after a stroke.

B. The hot water heater is set at 54°C (130° F): Hot water set at this temperature can lead to burns, posing a safety hazard.
C. Medications are stored in a clear bag: This is not a safety hazard; however, medications should be stored properly and organized for easy access.
D. Grab bars are installed in the bathroom: This is a safety feature that helps prevent falls and should be encouraged.
E. Area rugs are placed in the living room: Rugs can pose a tripping hazard, especially for stroke patients who may have mobility issues.

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.

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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?

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is ["A","B","E"]

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

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