A patient with a brain tumor has begun to exhibit signs of cachexia. What subsequent assessment should the nurse prioritize?

Correct Answer: C

Rationale: The correct answer is C: Assessment of nutritional status. Cachexia is a complex metabolic syndrome characterized by weight loss, muscle wasting, and weakness commonly seen in cancer patients. Assessing the patient's nutritional status is crucial to address the underlying causes of cachexia and to develop an appropriate management plan. This assessment includes evaluating dietary intake, weight changes, body composition, and nutritional deficiencies. Choice A: Assessment of peripheral nervous function is not the priority in this case as cachexia is primarily related to metabolic and nutritional issues rather than peripheral nervous system dysfunction. Choice B: Assessment of cranial nerve function is also not the priority since cachexia is not directly associated with cranial nerve dysfunction. Choice D: Assessment of respiratory status may be important in general patient care, but in this case, addressing the underlying nutritional issues that are contributing to cachexia should be the priority.

Correct Answer: C

Rationale: The correct answer is C because primary brain tumors originate from cells within the brain itself. These tumors develop from abnormal growth of brain cells. Choice A is incorrect as primary brain tumors do not come from outside the central nervous system (CNS). Choice B is incorrect as primary brain tumors do not typically start in glands. Choice D is incorrect as primary brain tumors do not arise from nerve tissue elsewhere in the body. In summary, the nurse should explain to the patient that the tumor originated from cells within his brain to provide accurate information about the nature of primary brain tumors.

Correct Answer: A

Rationale: The correct answer is A: Serum albumin level. Serum albumin is an important indicator of nutritional status, as low levels may indicate malnutrition or inflammation commonly seen in AIDS patients. Weight history (B) is also relevant as weight changes can reflect nutritional status. White blood cell count (C) is not directly related to nutritional status. Body mass index (D) is a calculation based on weight and height, not a direct measure of nutritional status. Blood urea nitrogen (E) is a measure of kidney function, not a specific indicator of nutritional status. Therefore, the nurse should primarily focus on assessing the patient's serum albumin level for nutritional status evaluation in this case.

Correct Answer: A

Rationale: The correct answer is A: Application of topical antibiotic ointment. After enucleation, there is a risk of infection at the surgical site. By applying topical antibiotic ointment as directed, the patient can help prevent infection and promote healing. This is a crucial aspect of postoperative care. B: Maintenance of a supine position for the first 48 hours postoperative is incorrect. Patients may be advised to avoid lying flat on their back to prevent complications such as pressure on the surgical site. C: Fluid restriction to prevent orbital edema is incorrect. Fluid restriction is not typically necessary post-enucleation unless specifically advised by the healthcare provider. D: Administration of loop diuretics to prevent orbital edema is incorrect. Loop diuretics are not typically used for preventing orbital edema post-enucleation. E: Use of an ocular pressure dressing is incorrect. While dressings may be used postoperatively, the application of topical antibiotic ointment is more

Correct Answer: B

Rationale: Interdisciplinary collaboration involves clinicians from different backgrounds integrating their separate plans of care, ensuring a holistic approach to patient care. This fosters a comprehensive understanding of the patient's needs and individualized care. In contrast, multidisciplinary practice involves clinicians working independently without integrating their plans, potentially leading to fragmented care. Choice A is incorrect as interdisciplinary collaboration does have a team leader to coordinate and facilitate communication among team members. Choice C is incorrect because while communication and cooperation are essential in interdisciplinary collaboration, the key distinction is the integration of different perspectives and plans of care. Choice D is incorrect as interdisciplinary collaboration goes beyond just medical expertise and patient preference, involving professionals from various disciplines working together to address all aspects of patient care.

Correct Answer: A

Rationale: The correct answer is A: Teach the patient how to self-cath the pouch. In a continent urinary reservoir, patients need to catheterize the pouch several times a day. This is essential for emptying the urine from the pouch as the ileocecal valve creates a one-way valve. Teaching the patient how to self-catheterize ensures proper and timely drainage, preventing complications like urinary retention. Self-catheterization also empowers the patient to take an active role in managing their continence. Summary of other choices: B: Kegel exercises are ineffective for a patient with a continent urinary reservoir as they do not address the need for catheterization. C: Changing the collection pouch is not the primary action needed for a continent urinary reservoir. Catheterization is essential for drainage. D: The Valsalva technique is not appropriate for voiding in a continent urinary reservoir. Catheterization is the recommended method for emptying the pouch.

Correct Answer: B

Rationale: The correct answer is B because verifying tube placement before feeding is essential to prevent pulmonary aspiration. If the tube is not correctly positioned in the stomach, there is a risk of feeding going into the lungs. Observing the color of gastric contents (A) may not always indicate correct placement. Adding blue food coloring (C) is unnecessary and could cause confusion. Running the formula over 12 hours (D) does not address the risk of pulmonary aspiration and does not ensure proper tube placement.

Correct Answer: B

Rationale: The correct answer is B) Impaired Skin Integrity Related to Kaposis Sarcoma. Kaposis sarcoma can cause skin lesions that may lead to impaired skin integrity due to tissue breakdown. The nurse should prioritize interventions to prevent infection and promote wound healing. Choice A is incorrect because Disuse Syndrome is not directly related to Kaposis Sarcoma. Choice C, Diarrhea, is not a common complication of Kaposis Sarcoma. Choice D, Impaired Swallowing, is not typically associated with Kaposis Sarcoma.

Correct Answer: D

Rationale: Correct Answer: D Rationale: 1. Clear, watery fluid draining from the ear post-accident indicates a possible cerebrospinal fluid (CSF) leak, a serious condition requiring immediate medical attention to prevent complications such as meningitis. 2. CSF leak can result from a basilar skull fracture, common in head injuries like motorcycle accidents. 3. Prompt reporting of this finding by the nurse is crucial for timely intervention and prevention of potential life-threatening complications. Summary: A: Visualizing the malleus during otoscopic examination is normal and not an immediate concern in this scenario. B: A pearly gray tympanic membrane is a normal finding and does not indicate a serious issue post-accident. C: Tenderness in the mastoid area may suggest injury but is not as urgent as clear, watery fluid drainage indicative of a CSF leak.