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 C
Explanation
Choice A rationale:
Allergic reactions to eggs are a concern with some vaccines, but the varicella vaccine is generally considered safe for children with egg allergies.
Choice B rationale:
The varicella vaccine is typically given in two doses, not three. Choice C rationale:
Children should avoid taking aspirin for about 6 weeks after receiving the varicella vaccine to reduce the risk of Reye's syndrome, a rare but serious condition associated with aspirin use during viral infections.
Choice D rationale:
The varicella vaccine is usually administered subcutaneously, not into the muscle.
Correct Answer is C
Explanation
Choice A rationale:
Chlamydia is a bacterial infection, so it is treated with antibiotics, not antiviral medications.
Choice B rationale:
Clients should abstain from sexual intercourse until the treatment course is completed to prevent transmission.
Choice C rationale:
Chlamydia infections are often asymptomatic in both males and females, which can lead to undiagnosed and untreated infections. Routine screening is important to detect and treat infections early.
Choice D rationale:
The recommended frequency for chlamydia screening in female clients at risk is annually, not every 2 years.
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