ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 66 : Management of Patients with Neurologic Dysfunction Questions
Question 1 of 5
The nurse is providing care for a patient who is unconscious. What nursing intervention takes highest priority?
Correct Answer: B
Rationale: Maintaining a patent airway is critical for an unconscious patient to ensure oxygenation and prevent aspiration. Other interventions, while important, are secondary to airway management.
Question 2 of 5
The nurse is caring for a patient in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the patients mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurses most appropriate action?
Correct Answer: C
Rationale: The CPP (MAP - ICP = 55 mm Hg) is low; normal is 70-100 mm Hg. Interventions to increase CPP are needed to prevent neurologic damage. High Fowlers, diuretics, or craniotomy may worsen the condition.
Question 3 of 5
The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of deficient fluid volume related to fluid restriction and osmotic diuretic use. What would be an appropriate intervention for this diagnosis?
Correct Answer: B
Rationale: Monitoring serum electrolytes adjusts fluid and electrolyte therapy in patients with deficient fluid volume post-craniotomy. Positioning, NPO status, and ABG monitoring do not directly address this diagnosis.
Question 4 of 5
A patient with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate?
Correct Answer: D
Rationale: Loosening restrictive clothing prevents injury during a seizure. Restraining or inserting an airway can cause harm, and high Fowlers is inappropriate during a seizure.
Question 5 of 5
A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the patients plan of care?
Correct Answer: C
Rationale: Phenytoin can cause gingival hyperplasia, making thorough oral hygiene essential. Pulse oximetry, low-protein diet, and fluid restriction are not related to phenytoin's adverse effects.