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 A

Explanation

Choice A reason: Maintaining a flat lying position for 14 hours following the procedure is the highest priority teaching point for the patient who had a lumbar puncture. It helps to prevent cerebrospinal fluid leakage and post-lumbar puncture headache, which can be severe and debilitating.

Choice B reason: Muscular discomfort is expected after being in a curled position for a period of time, but it is not the highest priority teaching point for the patient who had a lumbar puncture. It is a common and mild side effect that can be relieved by analgesics, massage, or heat therapy.

Choice C reason: Resuming oral intake immediately after the procedure is not a priority teaching point for the patient who had a lumbar puncture. It is not contraindicated, but it is not essential either. The patient should drink plenty of fluids to replenish the cerebrospinal fluid and prevent dehydration.

Choice D reason: Mild pain is expected at the needle insertion site, but it is not the highest priority teaching point for the patient who had a lumbar puncture. It is a common and mild side effect that can be relieved by analgesics, ice packs, or dressing.

A. Sudden unconsciousness, unresponsiveness, and apnea. B. Increased temperature, blood pressure, heart rate, and respirations. C. Changes in vision and personality, and headache upon awakening. D. Fever, increased white blood cell count, and decreased appetite.

Correct Answer is C

Explanation

Choice A reason: Sudden unconsciousness, unresponsiveness, and apnea are not typical symptoms of a brain tumor. They are more likely to indicate a stroke, seizure, or cardiac arrest.

Choice B reason: Increased temperature, blood pressure, heart rate, and respirations are not specific symptoms of a brain tumor. They are more likely to indicate an infection, inflammation, or stress.

Choice C reason: Changes in vision and personality, and headache upon awakening are common symptoms of a brain tumor. They are caused by the pressure of the tumor on the brain tissue and the cranial nerves.

Choice D reason: Fever, increased white blood cell count, and decreased appetite are not typical symptoms of a brain tumor. They are more likely to indicate a systemic infection or malignancy.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assisting the neurologist with a lumbar puncture on a patient with possible meningitis. Which post-procedure teaching point is the highest priority for the patient?

Correct Answer is A

Explanation

Which early symptoms in a focused assessment by the nurse may indicate the presence of a brain tumor?

Correct Answer is C

Explanation

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