You are caring for a patient with a recurrent glioblastoma who is receiving dexamethasone (Decadron) 4 mg IV every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information concerns you the most?

Correct Answer: A

Rationale: In this scenario, the correct answer is option A - "The patient does not recognize family members." This is the most concerning assessment information as it could indicate a decline in neurological function and potential signs of increased intracranial pressure or neurological deterioration. Option B - "The blood glucose level is 234 mg/dL" is not the most concerning in this context as elevated blood glucose levels can be managed medically and are not directly indicative of immediate neurological deterioration. Option C - "The patient complains of a continued headache" is not as concerning as the patient's presenting symptoms of right arm weakness and headache are the reasons for the current treatment. However, persistent headache should be monitored and managed. Option D - "The daily weight has increased 1 kg" is also not as concerning as the other options in the context of a patient with a recurrent glioblastoma. Weight gain can be attributed to various factors including fluid retention, nutritional status, or medication effects. In an educational context, understanding the rationale behind the correct answer helps healthcare providers prioritize assessments and interventions for patients with neurological conditions. Recognizing changes in cognition and mental status is crucial in the care of patients with brain tumors to prevent potential complications and provide timely interventions. This case highlights the importance of thorough neurological assessments and vigilance in monitoring subtle changes in a patient's condition, especially in the context of a known brain tumor.

Correct Answer: C

Rationale: In this scenario, the correct answer is option C: Respiratory rate. When Joe arrives in the emergency room, assessing his respiratory rate should be the nurse's priority. This is because an abnormal respiratory rate could indicate immediate life-threatening issues such as compromised airway, respiratory distress, or inadequate oxygenation, which require prompt intervention to ensure patient safety and prevent further deterioration. Option A: Movement of fingers is important for neurological assessment but is not the priority in this situation. Respiratory function takes precedence over extremity movement. Option B: Pain sensation in legs is relevant for assessing neurological function, but it is not as critical as assessing respiratory status in an emergency situation. Option D: Temperature sensation in arms is also important in a neurological assessment, but it is not as urgent as assessing respiratory rate. Educationally, this question highlights the importance of triaging and prioritizing assessments in emergency situations based on the ABCs (Airway, Breathing, Circulation). It reinforces the need for nurses to quickly identify and address life-threatening issues to provide timely and effective care to patients in critical conditions. By understanding the rationale behind prioritizing assessments, nurses can improve their clinical decision-making skills and enhance patient outcomes in emergency settings.

Correct Answer: C

Rationale: In this scenario, the correct answer is option C) express recognition of his difficulty and efforts to communicate. This option is the most appropriate therapeutic approach because it acknowledges the patient's struggle with communication, validates their efforts, and shows empathy. By recognizing the patient's difficulty and efforts, the healthcare provider can help in building a supportive and understanding environment for the patient, which can positively impact their emotional well-being. Option A) anticipate his needs to minimize efforts to talk is incorrect as it does not address the emotional aspect of the patient's reaction. It may inadvertently contribute to the patient feeling misunderstood or not valued for their communication attempts. Option B) respect his need to grieve is also incorrect as aphasia is not typically associated with grieving but rather the frustration of impaired communication. While emotional support is important, grieving might not be the most relevant response in this context. Option D) keep verbal stimulation to a minimum is not the best approach either, as it does not actively address the patient's emotional response to their condition. It may lead to further isolation and frustration for the patient, rather than helping them cope with their feelings. In an educational context, understanding the emotional impact of neurological conditions like aphasia is crucial for healthcare providers. By choosing the appropriate therapeutic approach, providers can not only support patients in their communication challenges but also help improve their overall well-being and quality of life. Effective communication strategies play a significant role in patient-centered care and can enhance the therapeutic relationship between healthcare providers and patients.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) "Those awful muscle spasms have let up." This response indicates that the medication, methocarbamol (Robaxin), has been effective in relieving the muscle spasms, which is its intended therapeutic effect. Mrs. Iris experiencing a reduction in muscle spasms is a positive outcome and suggests that the medication is working as expected. Option A) "I was thirsty after that medication" is unrelated to the effectiveness of methocarbamol in managing muscle spasms. Option B) "I have been urinating a lot today" is not a typical indicator of methocarbamol's effectiveness. Option D) "The swelling in my leg seems to have gone down" is also not a direct indicator of the medication's effectiveness in treating muscle spasms. Educationally, understanding how to assess the effectiveness of medications is crucial for healthcare professionals. It allows them to monitor the patient's response to treatment accurately and make informed decisions regarding ongoing care. In the context of neurological conditions, being able to interpret patient responses to medications is essential for optimizing patient outcomes and ensuring safe and effective management of symptoms.

Correct Answer: A

Rationale: In this question, the correct answer is option A) Symptoms of gastric irritation. Gold therapy is a treatment used for certain autoimmune diseases like rheumatoid arthritis, but it can have side effects. Gastric irritation is a common side effect of gold therapy due to its potential to irritate the lining of the stomach and cause symptoms like nausea, vomiting, or abdominal pain. Option B) Generalized edema is less likely to be associated with gold therapy and is not a typical side effect of this treatment. Edema is more commonly linked to conditions like heart failure or kidney disease. Option C) Elevated blood pressure is not a known side effect of gold therapy. While some medications can lead to changes in blood pressure, gold therapy is not typically associated with this particular side effect. Option D) Symptoms of visual disturbance are not typically seen as side effects of gold therapy. Visual disturbances can be associated with other medications or conditions, but they are not a common side effect of gold therapy specifically. In an educational context, understanding the side effects of different treatments is crucial for healthcare professionals to provide safe and effective care to patients. By knowing the potential adverse effects of medications like gold therapy, healthcare providers can monitor patients for signs of complications and take appropriate actions to mitigate any risks. It is important for students and practitioners to be able to differentiate between common side effects of treatments to ensure patient safety and well-being.