The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment?

Correct Answer: C

Rationale: The correct answer is C because assessing the level of consciousness, motor function, pupillary response, and vital signs are crucial indicators of increased intracranial pressure after neurosurgery. Level of consciousness can indicate neurological changes, motor function may show signs of weakness or paralysis related to brain damage, pupillary response can reflect brainstem function, and vital signs can reveal changes in cerebral perfusion. Choice A is incorrect because it does not include vital signs, which are essential in monitoring for increased intracranial pressure. Choice B is incorrect as it does not cover pupillary response, which is a key indicator of brainstem function. Choice D is incorrect as it lacks the assessment of vital signs, which are vital in detecting changes in cerebral perfusion.

Correct Answer: D

Rationale: The correct answer is D. 1. Monitoring for changes in the patient's condition is crucial to identify any deterioration or improvement. 2. Assessing for dehydration or infection is important as these conditions can cause confusion in elderly patients. 3. Rechecking vital signs may not provide additional information if they are within normal limits. 4. Obtaining a complete neurologic examination is not necessary at this point as the patient's confusion may be due to a more common cause like dehydration or infection. 5. Administering a sedative to relieve confusion is not appropriate without identifying and addressing the underlying cause. In summary, option D is the best course of action as it focuses on monitoring the patient's condition, assessing for potential causes of confusion, and addressing any underlying issues.

Correct Answer: C

Rationale: Rationale: Choice C is correct because it directly addresses circadian rhythms by asking about the patient's best and worst times of day, which helps assess their sleep-wake cycle disturbances common in depression. Choices A and D focus on hallucinations and cognitive functioning, not circadian rhythms. Choice B is related to memory impairment, not circadian rhythm disturbances.

Correct Answer: D

Rationale: The correct answer is D, Benzodiazepines. In acute anxiety, fast-acting anxiolytics like benzodiazepines are effective in providing immediate relief by enhancing the effects of GABA neurotransmitter, reducing anxiety symptoms quickly. Tricyclic antidepressants (A) are not ideal for acute anxiety due to slow onset of action. Atypical antipsychotics (B) are not first-line treatment for anxiety. Anticonvulsants (C) are not typically used for acute anxiety.

Correct Answer: A

Rationale: The correct answer is A: mood improvement. SSRI medications are primarily used to treat depression and anxiety disorders by increasing serotonin levels in the brain, which can lead to improved mood. Outcome criteria for a patient taking an SSRI should focus on monitoring and assessing mood changes to evaluate the effectiveness of the medication. B: Logical thought processes is incorrect because SSRI medications do not directly target cognitive processes, so it is not a specific outcome criteria related to SSRI use. C: Reduced levels of motor activity is incorrect because SSRI medications do not typically cause significant changes in motor activity as a primary effect, so it is not a relevant outcome criteria for monitoring patients on SSRIs. D: Decreased extrapyramidal symptoms is incorrect because extrapyramidal symptoms are typically associated with antipsychotic medications, not SSRIs. Monitoring for extrapyramidal symptoms would not be a relevant outcome criteria for a patient taking an SSRI.