A patient had a craniotomy one hour after a motor vehicle accident. The nurse evaluates pupillary response to:

assess the patient for potential visual deficits.

assess the patient's level of consciousness.

assess the patient for increased intracranial pressure.

assess the patient for cerebrospinal fluid leakage.

Answer and Explanation

The Correct Answer is C

Choice A reason: Assessing the patient for potential visual deficits is not the primary purpose of evaluating pupillary response. Visual deficits may result from damage to the optic nerve or the occipital lobe, but they are not directly related to pupillary response.

Choice B reason: Assessing the patient's level of consciousness is an important part of the neurological assessment, but it is not done by evaluating pupillary response alone. Level of consciousness is determined by observing the patient's responsiveness to verbal and physical stimuli, as well as their orientation to person, place, time, and situation.

Choice C reason: Assessing the patient for increased intracranial pressure is the best explanation for evaluating pupillary response. Increased intracranial pressure is a life-threatening condition that can result from brain swelling, bleeding, or infection. It can cause compression of the brainstem and the cranial nerves, leading to changes in pupillary size, shape, and reactivity. Pupillary response is a sensitive indicator of intracranial pressure and brainstem function.

Choice D reason: Assessing the patient for cerebrospinal fluid leakage is not the main reason for evaluating pupillary response. Cerebrospinal fluid leakage can occur after a craniotomy due to a tear in the dura mater, the membrane that covers the brain and spinal cord. It can cause symptoms such as headache, nausea, vomiting, and meningitis. However, it does not affect pupillary response unless it causes increased intracranial pressure.

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Correct Answer is C

Explanation

Choice A reason: This is incorrect. Apples, oranges and strawberries are good sources of vitamin C, which can help with iron absorption, but they are not high in iron content themselves. The patient should eat foods that are rich in both iron and vitamin C.

Choice B reason: This is incorrect. Tuna fish, white bread and green vegetables are not high in iron content either. Tuna fish is a source of protein, but it has less iron than other types of meat or fish. White bread is refined and has less iron than whole grain bread. Green vegetables have some iron, but not enough to meet the daily requirements.

Choice C reason: This is correct. Lean beef, raisins and prunes are high in iron content and can help the patient with iron deficiency anemia. Lean beef is a source of heme iron, which is more easily absorbed by the body than non-heme iron from plant sources. Raisins and prunes are dried fruits that have more iron than fresh fruits.

Choice D reason: This is incorrect. White chicken meat, whole milk and rice are not high in iron content either. White chicken meat has less iron than dark chicken meat or red meat. Whole milk is a source of calcium, which can interfere with iron absorption. Rice is a source of carbohydrates, but it has less iron than other grains or legumes.

A. "Try relaxation and warm moist compresses for your headaches and document your response." B. "Keep a diary of your headaches, recording symptoms, timing, and headache triggers." C. "Call and come in the next time you have a headache so you can be examined." D. "Keep track of how many headaches you have before you come in."

Correct Answer is B

Explanation

Choice A reason: "Try relaxation and warm moist compresses for your headaches and document your response." is not the best instruction by the nurse to gather additional data before the appointment. It is a suggestion for self-care and pain relief, but it does not provide any information about the cause, type, or severity of the headaches.

Choice B reason: "Keep a diary of your headaches, recording symptoms, timing, and headache triggers." is the best instruction by the nurse to gather additional data before the appointment. It is a useful tool for collecting objective and subjective data about the headaches, such as their frequency, duration, intensity, location, quality, associated symptoms, and precipitating factors. This can help the primary care practitioner to diagnose the type of headache, such as migraine, tension, or cluster, and prescribe the appropriate treatment.

Choice C reason: "Call and come in the next time you have a headache so you can be examined." is not the best instruction by the nurse to gather additional data before the appointment. It is a suggestion for urgent care, but it does not provide any information about the history, pattern, or characteristics of the headaches.

Choice D reason: "Keep track of how many headaches you have before you come in." is not the best instruction by the nurse to gather additional data before the appointment. It is a simple measure of the quantity of the headaches, but it does not provide any information about the quality, severity, or triggers of the headaches.

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