During an assessment, a patient asks the nurse if "something is burning." The nurse realizes that this patient could be demonstrating:

Question

1. Engorged nasal passages
2. A focal seizure
3. A way to have the nurse leave to check if something is burning
4. Increased intracranial pressure

Answer 1

2
Rationale 1: Engorged nasal passages usually result in the loss of smell, not the presence of unusual smells.
Rationale 2: Focal symptoms can occur in patients with brain tumors. The nurse should question the patient about any experienced symptoms such as muscle twitching or jerking of an arm or leg, abnormal smells or tastes, problems with speech, or numbness and tingling.
Rationale 3: This action is usually taken after the nurse has fully assessed the patient for neurologic changes. Priority care would include providing safety measures to protect the patient.
Rationale 4: The initial changes associated with increased intracranial pressure are subtle changes in level of consciousness such as alertness, changes in orientation, and motor and sensory deficits. Seizure activity is a late sign.