NUR360 Exam 3
An unconscious patient with a traumatic head injury has a blood pressure of 130/76 mm Hg, and an intracranial pressure (ICP) of 20 mm Hg. The nurse will calculate the cerebral perfusion pressure (CPP) as ____ mm Hg.
74
During a well woman physical exam, a 43-year-old patient asks about her risk for breast cancer. Which question is most pertinent for the nurse to ask?
"At what age did you start having menstrual periods?" Early menarche and late menopause are risk factors for breast cancer because of the prolonged exposure to estrogen that occurs. Cigarette smoking, breast trauma, and fibrocystic breast changes are not associated with increased breast cancer risk.
The nurse provides discharge teaching for a 61-year-old patient who has had a left modified radical mastectomy and lymph node dissection. Which statement by the patient indicates that teaching has been successful?
"I will avoid reaching over the stove with my left hand." The patient should avoid any activity that might injure the left arm, such as reaching over a burner. If the left arm exercises are painful, analgesics should be used and the exercises continued in order to restore strength and range of motion. The left arm should be elevated at or above heart level and should be used to improve range of motion and function.
Which patient statement indicates that the nurse's teaching about tamoxifen (Nolvadex) has been effective?
"I will call if I have any eye problems." Retinopathy, cataracts, and decreased visual acuity should be immediately reported because it is likely that the tamoxifen will be discontinued or decreased. Tamoxifen treatment generally lasts 5 years. Hot flashes are an expected side effect of tamoxifen. Leg cramps may be a sign of deep vein thrombosis, and the patient should immediately notify the health care provider if pain occurs.
A nurse is teaching a group of business people about disease transmission. He knows that he needs to reeducate when one of the participants states which of the following?
"If I don't feel sick, then I don't have to worry about transmitted diseases." People can transmit pathogens even if they don't currently feel ill. Some carriers never experience the full symptoms of a pathogen. Travelers may need different vaccinations when traveling to countries outside their own because of variations in prevalent microorganisms. Food and water supplies in foreign countries can contain microorganisms that will affect a body unaccustomed to their presence. Adequate hygiene is essential when in crowded, public spaces like planes and other forms of public transportation.
A patient who is scheduled for a right breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct?
"Malignant tumors may spread to other tissues or organs." The major difference between benign and malignant tumors is that malignant tumors invade adjacent tissues and spread to distant tissues and benign tumors never metastasize. The other statements are inaccurate. Both types of tumors may cause damage to adjacent tissues. Malignant cells do not reproduce more rapidly than normal cells. Benign tumors do not usually recur.
A patient newly diagnosed with stage I breast cancer is discussing treatment options with the nurse. Which statement by the patient indicates that additional teaching may be needed?
"Mastectomy is the best choice to decrease the chance of cancer recurrence." The survival rates with lumpectomy and radiation or modified radical mastectomy are comparable. The other patient statements indicate a good understanding of stage I breast cancer treatment.
A patient who is diagnosed with cervical cancer that is classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is most appropriate?
"The cancer involves only the cervix." Cancer in situ indicates that the cancer is localized to the cervix and is not invasive at this time. Cell differentiation is not indicated by clinical staging. Because the cancer is in situ, the origin is the cervix. Further testing is not indicated given that the cancer has not spread.
A 46-year-old patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as
11 The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.
Which assessment finding in a 36-year-old patient is most indicative of a need for further evaluation?
A breast nodule that is 1 cm in size, nontender, and fixed Painless and fixed lumps suggest breast cancer. The other findings are more suggestive of benign processes such as fibrocystic breasts and fibroadenoma.
Which information will the nurse include in patient teaching for a 36-year-old patient who is scheduled for stereotactic core biopsy of the breast?
A local anesthetic will be given before the biopsy specimen is obtained. A local anesthetic is given before stereotactic biopsy. NPO status is not needed because no sedative drugs are given. The patient is placed in the prone position. A biopsy gun is used to obtain the specimens.
A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now complaining of a headache. Which prescribed interventions should the nurse implement first?
Administer IV 5% hypertonic saline. The patient's low sodium indicates that hyponatremia may be causing the cerebral edema. The nurse's first action should be to correct the low sodium level. Acetaminophen (Tylenol) will have minimal effect on the headache because it is caused by cerebral edema and increased intracranial pressure (ICP). Drawing ABGs and obtaining a CT scan may provide some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.
A patient with metastatic cancer of the colon experiences severe vomiting following each administration of chemotherapy. Which action, if taken by the nurse, is most appropriate?
Administer prescribed antiemetics 1 hour before the treatments. Treatment with antiemetics before chemotherapy may help prevent nausea. The patient should eat small, frequent meals. Offering food and beverages during chemotherapy is likely to cause nausea. The acidity of citrus fruits may be further irritating to the stomach.
A nursing manager is concerned about the number of infections on the hospital unit. What action by the manager would best help prevent these infections?
Auditing staff members' hand hygiene practices All methods will help prevent infection; however, health care workers' lack of hand hygiene is the biggest cause of healthcare-associated infections. The manager can start with a hand hygiene audit to see if this is a contributing cause.
A patient with cancer has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which nursing action is most appropriate?
Avoid giving the patient foods that are strongly disliked. The patient will eat more if disliked foods are avoided and foods that the patient likes are included instead. Additional spice is not usually an effective way to enhance taste. Adding baby meats to foods will increase calorie and protein levels, but does not address the issue of taste. The patient's poor intake is not caused by a lack of information about nutrition.
Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and respirations 26. Which set of vital signs, if taken 1 hour after admission, will be of most concern to the nurse?
Blood pressure 154/68, pulse 56, respirations 12 Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad. These findings indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.
A 68-year-old male patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by his spouse. Which action will the nurse take first?
Check oxygen saturation. Airway patency and breathing are the most vital functions, and should be assessed first. The neurologic assessments should be accomplished next and additional assessment after that.
A 20-year-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take?
Check the drainage for glucose content. Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage.
Which action by the nurse is most helpful to prevent clients from acquiring infections while hospitalized?
Consistently using appropriate hand hygiene Consistent practice of proper hand hygiene is the best method to prevent infection, as most healthcare-associated infections are due to staff members' contaminated hands. Assessing the client and monitoring laboratory values will help the nurse catch signs of infection quickly but will not prevent infection from occurring. Teaching visitors not to come see the client when they are ill will also help prevent infection, but not to the degree that hand hygiene will.
A client is hospitalized and on multiple antibiotics. The client develops frequent diarrhea. What action by the nurse is most important?
Consult with the provider about obtaining stool cultures. Hospitalized clients who have three or more stools a day for 2 or more days are suspected of having infection with Clostridium difficile. The nurse should inform the practitioner and request stool cultures. Frequent perianal care is important and can be delegated but is not the priority. The client does not necessarily need to be NPO; if the client is NPO, the nurse ensures he or she is getting appropriate IV fluids to prevent dehydration. Anti-diarrheal medication may or may not be appropriate, and the diarrhea serves as the portal of exit for the infection.
The nurse plans a presentation for community members about how to decrease the risk for antibiotic-resistant infections. Which information will the nurse include in the teaching plan (select all that apply)?
Continue taking antibiotics until all the medication is gone. Antibiotics may sometimes be prescribed to prevent infection. Unused antibiotics that are more than a year old should be discarded. Hand washing is effective in preventing many viral and bacterial infections All prescribed doses of antibiotics should be taken. In some situations, such as before surgery, antibiotics are prescribed to prevent infection. There should not be any leftover antibiotics because all prescribed doses should be taken. However, if there are leftover antibiotics, they should be discarded immediately because the number left will not be enough to treat a future infection. Hand washing is generally considered the single most effective action in decreasing infection transmission. Antibiotics are ineffective in treating viral infections such as influenza.
The nurse is caring for a patient who smokes 2 packs/day. To reduce the patient's risk of lung cancer, which action by the nurse is best?
Discuss the risks associated with cigarettes during every patient encounter. Teaching about the risks associated with cigarette smoking is recommended at every patient encounter because cigarette smoking is associated with multiple health problems. A tumor must be at least 0.5 cm large before it is detectable by current screening methods and may already have metastasized by that time. Oncofetal antigens such as CEA may be used to monitor therapy or detect tumor reoccurrence, but are not helpful in screening for cancer. The seven warning signs of cancer are actually associated with fairly advanced disease.
The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)?
Document the amount of drainage every eight hours. UAP education includes documentation of intake and output. The other actions are within the scope of practice and education of licensed nursing personnel.
A 42-year-old patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care?
Encourage family members to remain at the bedside. Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications. The use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim.
A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to maintain the patient's self-esteem?
Encourage the patient to purchase a wig or hat and wear it once hair loss begins. The patient is taught to anticipate hair loss and to be prepared with wigs, scarves, or hats. Limiting social contacts is not appropriate at a time when the patient is likely to need a good social support system. The damage occurs at the hair follicle and will occur regardless of gentle washing or use of a mild shampoo. The information that the hair will grow back is not immediately helpful in maintaining the patient's self-esteem.
A hospitalized client is placed on Contact Precautions. The client needs to have a computed tomography (CT) scan. What action by the nurse is most appropriate?
Ensure that the radiology department is aware of the isolation precautions. Clients in isolation should leave their rooms only when necessary, such as for a CT scan that cannot be done portably in the room. The nurse should ensure that the receiving department is aware of the isolation precautions needed to care for the client. The other options are not needed.
A 51-year-old patient with a small immobile breast lump is considering having a fine-needle aspiration (FNA) biopsy. The nurse explains that an advantage to this procedure is that
FNA is done in the outpatient clinic and results are available in 1 to 2 days. FNA is done in outpatient settings and results are available in 24 to 48 hours. No incision is needed. FNA may be guided by ultrasound, but not by mammogram. Because the immobility of the breast lump suggests cancer, further testing will be done if the FNA is negative.
The student nurse caring for clients understands that which factors must be present to transmit infection? (Select all that apply.)
Factors that must be present in order to transmit an infection include a host with a portal of entry, a mode of transmission, and a reservoir. Colonization is not one of these factors.
The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung. Which information should the nurse include about the patient's postoperative care?
Frequent use of an incentive spirometer Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis. In a pneumonectomy, chest tubes may or may not be placed in the space from which the lung was removed. If a chest tube is used, it is clamped and only released by the surgeon to adjust the volume of serosanguineous fluid that will fill the space vacated by the lung. If the cavity overfills, it could compress the remaining lung and compromise the cardiovascular and pulmonary function. Daily chest x-rays can be used to assess the volume and space.
The public health nurse is planning a program to decrease the incidence of meningitis in adolescents and young adults. Which action is most important?
Immunize adolescents and college freshman against Neisseria meningitides. The Neisseria meningitides vaccination is recommended for children ages 11 and 12, unvaccinated teens entering high school, and college freshmen. Hand washing may help decrease the spread of bacteria, but it is not as effective as immunization. Vaccination with Haemophilus influenzae is for infants and toddlers. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic.
Individuals of low socioeconomic status are at an increased risk for infection because of which of the following? (Select all that apply.)
Individuals of low socioeconomic status tend to be part of the underinsured or uninsured population. Lack of insurance decreases accessibility to health care in general and health screening services specifically. High costs of medication and nutritious food also make this population at higher risk for infection. Gender has not been shown to be an increased risk factor for infection in the lower socioeconomic population.
The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose. Which admission order should the nurse question?
Insert nasogastric tube to low suction. Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage. Insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold packs are appropriate orders.
The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness?
Intracranial pressure Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. Oxygen saturation will not directly improve as a result of mannitol administration.
A nurse receives report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has "a shift to the left" on the white blood cell count. What action by the nurse is most important?
Notify the provider and request antibiotics. A shift to the left indicates an increase in immature neutrophils and is often seen in infections, especially those caused by bacteria. The nurse should notify the provider and request antibiotics. Documentation and teaching need to be done, but the nurse needs to do more. The client does not need protective isolation.
During a routine health examination, a 40-year-old patient tells the nurse about a family history of colon cancer. Which action should the nurse take next?
Obtain more information from the patient about the family history. The patient may be at increased risk for colon cancer, but the nurse's first action should be further assessment. The other actions may be appropriate, depending on the information that is obtained from the patient with further questioning.
A client is admitted with possible sepsis. Which action should the nurse perform first?
Obtain specified cultures. Prior to administering antibiotics, the nurse obtains the ordered cultures. Broad-spectrum antibiotics will be administered until the culture and sensitivity results are known. Antipyretics are given if the client is uncomfortable; fever is a defense mechanism. Giving antipyretics does not take priority over obtaining cultures. The client may or may not need isolation.
A student nurse asks the nursing instructor why older adults are more prone to infection than other adults. What reasons does the nursing instructor give? (Select all that apply.)
Older adults have several age-related changes making them more susceptible to infection, including decreased immune function, decreased cough and gag reflex, decreased acidity of gastric secretions, thinning skin, and fewer lymphocytes and antibodies.
Which finding for a patient who has a head injury should the nurse report immediately to the health care provider?
Pale yellow urine output is 1200 mL over the last 2 hours. The high urine output indicates that diabetes insipidus may be developing, and interventions to prevent dehydration need to be rapidly implemented. The other data do not indicate a need for any change in therapy.
The nurse is working on a plan of care with her patient which includes turning and positioning and adequate nutrition to help the patient maintain intact skin integrity. The nurse helps the patient to realize that this breaks the chain of infection by eliminating which element?
Portal of entry Broken or impaired skin creates a portal of entry for pathogens. By maintaining intact tissue, the patient and the nurse have broken the chain of infection by eliminating a portal of entry. Host is incorrect because you are not eliminating the person or organism. Intact tissue does not eliminate the mode of transmission. Skin can still be used to transfer pathogens regardless of it being intact or broken. Intact skin does not eliminate the location for pathogens to live and grow.
Which nursing action should be included in the plan of care for a patient returning to the surgical unit following a left modified radical mastectomy with dissection of axillary lymph nodes?
Post a sign at the bedside warning against venipunctures or blood pressures in the left arm. The patient is at risk for lymphedema and infection if blood pressures or venipuncture are done on the right arm. The patient is taught to use the PCA as needed for pain control rather than at a set time. The nurse allows the patient to examine the incision and participate in care when the patient feels ready. Permanent breast prostheses are usually obtained about 6 weeks after surgery.
A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection cultured from the urine. What action by the nurse is most appropriate?
Prepare to administer vancomycin (Vancocin). Vancomycin is one of a few drugs approved to treat MRSA. The others include linezolid (Zyvox) and ceftaroline fosamil (Teflaro). Visitation does not need to be limited to immediate family only. Hand hygiene is performed before and after wearing gloves. A respirator is not needed, but if splashing is anticipated, a face shield can be used.
Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness?
Provide discharge instructions about monitoring neurologic status. A patient with a minor head trauma is usually discharged with instructions about neurologic monitoring and the need to return if neurologic status deteriorates. MRI, hospital admission, or surgery are not usually indicated in a patient with a concussion.
A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first?
Report the BP and ICP to the health care provider. Calculate the cerebral perfusion pressure (CPP): (CPP = mean arterial pressure [MAP] - ICP). MAP = DBP + 1/3 (systolic blood pressure [SBP] - diastolic blood pressure [DBP]). Therefore the (MAP) is 70 and the CPP is 56 mm Hg, which is below the normal of 60 to 100 mm Hg and approaching the level of ischemia and neuronal death. Immediate changes in the patient's therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation will also be done, but they are not the first actions that the nurse should take.
A nurse is observing as an unlicensed assistive personnel (UAP) performs hygiene and changes a client's bed linens. What action by the UAP requires intervention by the nurse?
Shaking dirty linens and placing them on the floor Shaking dirty linens (or even clean linens) can spread microbes through the air. Placing linens on the floor contaminates the floor surface and can lead to infection spread via shoes. The other actions are appropriate. If the client has a scalp infection or infestation, the UAP should wear gloves; otherwise it is not required.
A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether a patient is developing postconcussion syndrome?
Short-term memory Decreased short-term memory is one indication of postconcussion syndrome. The other data may be assessed but are not indications of postconcussion syndrome.
The nursing instructor explaining infection tells students that which factor is the best and most important barrier to infection?
Skin and mucous membranes The skin and mucous membranes are the most important barrier against infection. The other options are also barriers, but are considered secondary to skin and mucous membranes.
The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take?
Stop the infusion if swelling is observed at the site. Swelling at the site may indicate extravasation, and the IV should be stopped immediately. The medication generally should be given slowly to avoid irritation of the vein. The size of the catheter is not as important as administration of vesicants into a running IV line to allow dilution of the chemotherapeutic drug. These medications can be given through peripheral lines, although central vascular access devices (CVADs) are preferred.
A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have chemotherapy than surgery." Which response by the nurse is most appropriate?
Tell me what you know about the various treatments available. More assessment of the patient's concerns about surgery is indicated. An open-ended response will elicit the most information from the patient. The answer beginning, "Surgery is the treatment of choice" is accurate, but it discourages the patient from sharing concerns about surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the patient's reasons for not wanting surgery. Chemotherapy is the primary treatment for small cell lung cancer. In non-small cell lung cancer, chemotherapy may be used in the treatment of nonresectable tumors or as adjuvant therapy to surgery.
A 53-year-old woman at menopause is discussing the use of hormone therapy (HT) with the nurse. Which information about the risk of breast cancer will the nurse provide?
The patient and her health care provider must weigh the benefits of HT against the risks of breast cancer. Because HT has been linked to increased risk for breast cancer, the patient and provider must determine whether or not to use HT. Breast cancer incidence is increased in women using HT, independent of other risk factors. HT increases the risk for both non-BRCA-associated cancer and BRCA-related cancers. Alternative therapies can be used but are not consistent in relieving menopausal symptoms.
The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires the most rapid action by the nurse?
The patient is more difficult to arouse. The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (ICP) and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache and a slightly irregular apical pulse are not unusual in a patient after a head injury.
A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching?
The patient's visitors bring in some fresh peaches from home. Fresh, thinned-skin fruits are not permitted in a neutropenic diet because of the risk of bacteria being present. The patient should ambulate in the room rather than the hospital hallway to avoid exposure to other patients or visitors. Because overuse of soap can dry the skin and increase infection risk, showering every other day is acceptable. Careful cleaning after having a bowel movement will help prevent skin breakdown and infection.
he charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene?
The staff nurse suctions the patient routinely every 2 hours. Suctioning increases intracranial pressure, and should only be done when the patient's respiratory condition indicates it is needed. The other actions by the staff nurse are appropriate.
A patient with a large stomach tumor that is attached to the liver is scheduled to have a debulking procedure. Which information should the nurse teach the patient about the outcome of this procedure?
Tumor size will decrease and this will improve the effects of other therapy. A debulking surgery reduces the size of the tumor and makes radiation and chemotherapy more effective. Debulking surgeries do not control tumor growth. The tumor is debulked because it is attached to the liver, a vital organ (not to relieve pressure on the stomach). Debulking does not sever the sensory nerves, although pain may be lessened by the reduction in pressure on the abdominal organs.
A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action?
Unlicensed assistive personnel enter the patient's room without a mask. Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the foot and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis.
When assessing a 53-year-old patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider?
When assessing a 53-year-old patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider? Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension.
The nurse teaching a young women's community service group about breast self-examination (BSE) will include that
performing BSE after the menstrual period is more comfortable Performing BSE at the end of the menstrual period will reduce the breast tenderness associated with the procedure. The evidence is not clear that BSE reduces mortality from breast cancer. BSE should be done monthly. Annual mammograms are not routinely scheduled for women under age 40, and newer guidelines suggest delaying them until age 50.
When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as
decorticate posturing Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal.
The nurse admitting a patient who has a right frontal lobe tumor would expect the patient may have
impaired judgment. The frontal lobe controls intellectual activities such as judgment. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumor. Swallowing is controlled by the brainstem.
After a 48-year-old patient has had a modified radical mastectomy, the pathology report identifies the tumor as an estrogen-receptor positive adenocarcinoma. The nurse will plan to teach the patient about
tamoxifen (Nolvadex). Tamoxifen is used for estrogen-dependent breast tumors in premenopausal women. Raloxifene is used to prevent breast cancer, but it is not used postmastectomy to treat breast cancer. Estradiol will increase the growth of estrogen-dependent tumors. Trastuzumab is used to treat tumors that have the HER-2 receptor.
The nurse will teach a patient with metastatic breast cancer who has a new prescription for trastuzumab (Herceptin) that
the patient should call if she notices ankle swelling. Trastuzumab can lead to ventricular dysfunction, so the patient is taught to self-monitor for symptoms of heart failure. There is no need to monitor serum electrolyte levels. Hot flashes or changes in visual acuity may occur with tamoxifen, but not with trastuzumab.
