A nurse is assessing a client who is 4 hr postoperative following a craniotomy for the treatment of a benign brain tumor. Which of the following findings should the nurse identify as the priority?
15 mL of drainage in Hemovac
Periorbital ecchymosis
Nonreactive pupils
Hgb 11 g/dL
The Correct Answer is C
Choice A rationale:
Drainage in the Hemovac is an expected finding postoperatively and is not as urgent as nonreactive pupils.
Choice B rationale:
Periorbital ecchymosis (bruising around the eyes) is not uncommon after a craniotomy and is not as urgent as nonreactive pupils.
Choice C rationale:
Nonreactive pupils can indicate a neurological emergency, such as increased intracranial pressure or potential damage to the cranial nerves. This finding requires immediate attention to prevent further complications.
Choice D rationale:
Hemoglobin level of 11 g/dL is within a normal range and is not a priority concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Eliminating unhealthy foods is generally a good practice, but specific guidance related to managing hyperemesis gravidarum is needed.
Choice B rationale:
Dairy products can be included in the diet unless the client has a specific intolerance or allergy.
Choice C rationale:
Drinking water with each meal can be helpful, but avoiding dehydration is more important. Fluid intake should be consistent throughout the day.
Choice D rationale:
Hyperemesis gravidarum is a condition that causes severe nausea and vomiting during pregnancy, which can lead to dehydration, electrolyte imbalance, and weight loss. To prevent or reduce these complications, the nurse should instruct the client to eat foods at colder temperatures, as they are less likely to trigger nausea than hot or spicy foods. The client should also eat small, frequent meals and avoid foods that are greasy, fatty, or have strong odors.
Correct Answer is C
Explanation
Choice A rationale:
Taking a hot bath to relieve muscle spasms might exacerbate symptoms in individuals with multiple sclerosis due to heat sensitivity.
Choice B rationale:
Participating in high-impact exercise daily can be challenging for individuals with multiple sclerosis, who may experience fatigue and mobility issues.
Choice C rationale:
Adequate hydration is essential for individuals with multiple sclerosis to maintain overall health and support neurological function.
Choice D rationale:
Restricting daily intake of dietary fiber is not recommended, as fiber can aid in maintaining bowel regularity for individuals with multiple sclerosis.
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