Question

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

Answer 1

Correct Answers:

Changes in vision and personality, and headache upon awakening.

Rationale :

🔷 Early symptoms of brain tumors often affect areas responsible for vision and behavior.

🔷 Morning headaches are due to increased intracranial pressure (ICP) when lying flat overnight.

🔷 Tumors cause gradual neurologic deficits, not sudden collapse or infection-like symptoms.

🔷 Vision changes suggest involvement of the occipital or temporal lobe.

🔷 Personality shifts reflect frontal lobe involvement, common with slow-growing masses.

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Answer 2

Correct Answers:

Hypoglossal - Cranial Nerve XII

Rationale :

🟢 Cranial Nerve XII controls tongue movement, crucial for swallowing and speech.

🟢 In Parkinson's disease, dysphagia increases aspiration risk, so tongue coordination must be checked.

🟢 Asking a patient to move their tongue side to side tests motor integrity of this nerve.

🟢 Dysfunction in CN XII often causes slurred speech and ineffective food manipulation.

🟢 Proper assessment helps guide dietary modifications or referral to speech therapy.

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Answer 3

Correct Answers:

Flexion of the neck causes flexion of the hips and knees.

Rationale :

♦ A positive Brudzinski's sign indicates meningeal irritation, often from meningitis.

♦ When the neck is flexed, the body reflexively draws knees upward to reduce spinal strain.

♦ This involuntary movement reflects protective neuromuscular response.

♦ It helps differentiate meningitis from other neurologic conditions.

♦ This sign is paired with Kernig’s sign for comprehensive meningeal assessment.

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Answer 4

Correct Answers:

The person's cognitive and mental capacity will most likely remain intact throughout the disease progression.

Rationale :

🔶 In ALS, motor neurons degenerate but cognitive function remains unaffected in most cases.

🔶 Patients progressively lose control over voluntary muscles, including breathing and speech.

🔶 Families often fear cognitive decline, so it’s critical to clarify this distinction.

🔶 Preserved cognition allows the patient to participate in decision-making and care planning.

🔶 As respiratory muscles weaken, mechanical ventilation may be needed in late stages.

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Answer 5

Correct Answers:

Utilize approaches to minimize risk of infection and bleeding episodes.

Rationale :

💠 Chemotherapy suppresses bone marrow, increasing infection and bleeding risks.

💠 Leukemia compromises white blood cell and platelet production, leading to neutropenia and thrombocytopenia.

💠 Priority care involves neutropenic precautions, hand hygiene, and fall prevention.

💠 Nutritional and developmental needs are important but secondary to survival.

💠 Protection from infection directly reduces morbidity and mortality in pediatric oncology.

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Answer 6

Correct Answers:

chronic kidney disease

Rationale :

🔵 Erythropoietin, a hormone made in the kidneys, is deficient in chronic kidney disease (CKD).

🔵 Without erythropoietin, RBC production in bone marrow is suppressed, causing anemia.

🔵 CKD patients often require epoetin injections to stimulate RBC production.

🔵 Anemia in CKD is normocytic, normochromic, unlike nutritional anemias.

🔵 Diabetes and hypertension contribute to CKD but are not direct anemia causes.

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Answer 7

Correct Answers:

Morning

Rationale :

🟡 Myasthenia gravis causes progressive muscle fatigue that worsens as the day goes on.

🟡 Morning time provides the best muscular strength, improving safety and task success.

🟡 Bathing and exercising require sustained muscle effort, which declines later in the day.

🟡 Energy conservation is a major care strategy to prevent exhaustion or crisis.

🟡 Proper scheduling supports independence and functional mobility.

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Answer 8

Correct Answers:

Elevate the head of the bed 20 to 30 degrees.

Rationale :

✳️ Elevating HOB reduces intracranial pressure (ICP) and promotes venous drainage.

✳️ This is critical following craniotomy to prevent swelling or brain herniation.

✳️ Frequent stimulation increases metabolic demand, worsening pressure.

✳️ Lighting and frequent movement are not helpful in managing ICP postoperatively.

✳️ Maintain neutral head alignment and avoid straining or coughing.

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Answer 9

Correct Answers:

Maintain pressure to the puncture site and observe for drainage.

Rationale :

◾ After a lumbar puncture, the main concern is CSF leakage, which can cause severe headache.

◾ Applying pressure ensures proper closure of the dura to prevent fluid loss.

◾ Monitoring for bloody or clear drainage is essential for detecting complications.

◾ Other actions like pain assessment are secondary and supportive.

◾ Leakage or persistent drainage may need provider intervention or blood patch.

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Answer 10

Correct Answers:

Maintain a flat lying position for 14 hours following the procedure.

Rationale :

✅ Lying flat after LP prevents post-dural puncture headache due to CSF leakage.

✅ This helps maintain intracranial pressure balance and promotes healing at puncture site.

✅ Early mobilization increases risk of orthostatic headache.

✅ Other symptoms like pain or discomfort are expected but not prioritized.

✅ This teaching improves compliance and reduces hospital readmission for complications.

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Massbay Community College Med Surg exam 2

No.

1 :
Which early symptoms in a focused assessment by the nurse may indicate the presence of a brain tumor?

2 :
The nurse is evaluating the cranial nerves of a person with Parkinson disease who has difficulty swallowing foods. The nurse asks the patient to stick out their tongue and move it rapidly from side to side. The nurse is assessing which cranial nerve?

3 :
The nurse assesses a patient who potentially may have meningitis. The patient demonstrates a positive Brudzinski's sign with which changes in position.

4 :
The nurse is educating the family about anticipated changes during the late stages of amyotrophic lateral sclerosis (ALS) for their father. What teaching point is most important for the nurse to include?

5 :
The nurse is caring for a 9-year-old undergoing chemotherapy to treat leukemia. Select the priority nursing goal for the child's plan of care.

6 :
The nurse is caring for a patient with anemia. Their medical history includes diabetes mellitus Type 1, hypertension, chronic kidney disease, and peripheral vascular disease. Which condition most likely contributes to their anemia?

7 :
You are a home health nurse providing care to a patient with myasthenia gravis. Today you plan on helping the patient with bathing and exercising. When would be the best time to visit the patient to help with these tasks?

8 :
Postoperative care for a patient having a craniotomy to relieve increased intracranial pressure, the nurse should implement which intervention?

9 :
The nurse is caring for a patient undergoing a lumbar puncture by the provider. Select the priority nursing intervention the nurse would complete after the procedure.

10 :
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?

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Massbay Community College Med Surg exam 2

No.

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

2 : The nurse is evaluating the cranial nerves of a person with Parkinson disease who has difficulty swallowing foods. The nurse asks the patient to stick out their tongue and move it rapidly from side to side. The nurse is assessing which cranial nerve?

3 : The nurse assesses a patient who potentially may have meningitis. The patient demonstrates a positive Brudzinski's sign with which changes in position.

4 : The nurse is educating the family about anticipated changes during the late stages of amyotrophic lateral sclerosis (ALS) for their father. What teaching point is most important for the nurse to include?

5 : The nurse is caring for a 9-year-old undergoing chemotherapy to treat leukemia. Select the priority nursing goal for the child's plan of care.

6 : The nurse is caring for a patient with anemia. Their medical history includes diabetes mellitus Type 1, hypertension, chronic kidney disease, and peripheral vascular disease. Which condition most likely contributes to their anemia?

7 : You are a home health nurse providing care to a patient with myasthenia gravis. Today you plan on helping the patient with bathing and exercising. When would be the best time to visit the patient to help with these tasks?

8 : Postoperative care for a patient having a craniotomy to relieve increased intracranial pressure, the nurse should implement which intervention?

9 : The nurse is caring for a patient undergoing a lumbar puncture by the provider. Select the priority nursing intervention the nurse would complete after the procedure.

10 : 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?

1 :
Which early symptoms in a focused assessment by the nurse may indicate the presence of a brain tumor?

2 :
The nurse is evaluating the cranial nerves of a person with Parkinson disease who has difficulty swallowing foods. The nurse asks the patient to stick out their tongue and move it rapidly from side to side. The nurse is assessing which cranial nerve?

3 :
The nurse assesses a patient who potentially may have meningitis. The patient demonstrates a positive Brudzinski's sign with which changes in position.

4 :
The nurse is educating the family about anticipated changes during the late stages of amyotrophic lateral sclerosis (ALS) for their father. What teaching point is most important for the nurse to include?

5 :
The nurse is caring for a 9-year-old undergoing chemotherapy to treat leukemia. Select the priority nursing goal for the child's plan of care.

6 :
The nurse is caring for a patient with anemia. Their medical history includes diabetes mellitus Type 1, hypertension, chronic kidney disease, and peripheral vascular disease. Which condition most likely contributes to their anemia?

7 :
You are a home health nurse providing care to a patient with myasthenia gravis. Today you plan on helping the patient with bathing and exercising. When would be the best time to visit the patient to help with these tasks?

8 :
Postoperative care for a patient having a craniotomy to relieve increased intracranial pressure, the nurse should implement which intervention?

9 :
The nurse is caring for a patient undergoing a lumbar puncture by the provider. Select the priority nursing intervention the nurse would complete after the procedure.

10 :
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?