A charge nurse is reviewing the status of patients in the critical care unit. Which patient should the charge nurse notify the organ procurement team to evaluate for possible organ donation?

A 72-year-old client with a brain tumor, GCS of 5 and decerebrate posturing.

A 24-year-old client after a motor vehicle accident with a Glasgow Coma Scale (GCS) of 3 and no activity on electroencephalogram.

A 68-year-old male admitted with a massive stroke and GCS of 6.

A 50-year-old female client after a motor vehicle accident and surgical evacuation of an epidural hematoma, Glasgow Coma Scale 12.

Answer and Explanation

The Correct Answer is B

Choice A reason:

A 72-year-old client with a brain tumor, GCS of 5, and decerebrate posturing may not be an ideal candidate for organ donation due to age and underlying cancer, which can affect organ viability.

Choice B reason:

A 24-year-old client after a motor vehicle accident with a GCS of 3 and no activity on electroencephalogram is a prime candidate for organ donation. The lack of brain activity indicates brain death, and the patient's young age and otherwise healthy organs make them suitable for transplantation.

Choice C reason:

A 68-year-old male with a massive stroke and GCS of 6 has significant neurological impairment but is not necessarily brain dead. Further evaluation would be required, but this patient may not meet the criteria for brain death necessary for organ donation.

Choice D reason:

A 50-year-old female with a GCS of 12 after surgical evacuation of an epidural hematoma is not an ideal candidate for organ donation at this time as they have a higher level of consciousness and potential for recovery.

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Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason:

Autonomic dysreflexia is a serious condition that can occur in individuals with spinal cord injuries, particularly those at or above the T6 level. It is a secondary injury mechanism that results from the autonomic nervous system's abnormal response to stimuli below the level of injury, leading to severe hypertension and other complications.

Choice B reason:

Ischemia, or reduced blood flow, is a common cause of secondary injury following a spinal cord injury. It can result from initial trauma or subsequent swelling and vascular damage, leading to further cell death and tissue damage.

Choice C reason:

Edema, or swelling, is another cause of secondary injury in spinal cord injuries. The inflammatory response to injury can cause fluid accumulation, increasing pressure within the spinal column and exacerbating damage to spinal cord tissues.

Choice D reason:

Axial loading is a primary mechanism of spinal cord injury, not a secondary injury cause. It refers to the vertical force applied along the axis of the spine, typically resulting from falls or direct blows, leading to compression and potential fractures.

Choice E reason:

Hemorrhage, or bleeding, is a significant cause of secondary injury in spinal cord trauma. It can result from blood vessel damage at the injury site, leading to increased pressure, further tissue damage, and impaired blood flow.

A. Specific gravity. B. Level of consciousness. C. Urine output. D. Blood pressure.

Correct Answer is C

Explanation

Choice A reason:

A decrease in specific gravity is not the primary therapeutic outcome of desmopressin in the treatment of diabetes insipidus. Desmopressin works by increasing water reabsorption in the kidneys, which leads to a decrease in urine output and an increase in urine concentration, reflected by an increase, not a decrease, in specific gravity.

Choice B reason:

A decrease in the level of consciousness is not an intended therapeutic outcome and would be concerning if observed. Desmopressin aims to control symptoms of diabetes insipidus, not alter the patient’s mental status.

Choice C reason:

A decrease in urine output is the primary therapeutic outcome of desmopressin in a patient with diabetes insipidus. Desmopressin mimics the action of antidiuretic hormone (ADH), leading to increased water reabsorption in the kidneys and reduced urine volume.

Choice D reason:

Desmopressin does not primarily aim to decrease blood pressure. Its main effect is on water reabsorption in the kidneys, thereby reducing urine output. While it can have some impact on blood pressure, this is not its primary therapeutic outcome.

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A charge nurse is reviewing the status of patients in the critical care unit. Which patient should the charge nurse notify the organ procurement team to evaluate for possible organ donation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nursing student studying spinal cord injury recognizes all of the following to be causes of secondary injuries:

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is caring for a patient with a head injury who has developed diabetes insipidus and is receiving desmopressin. The nurse understands the therapeutic outcome is a decrease in:

Correct Answer is C

Explanation

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A nursing student studying spinal cord injury recognizes all of the following to be causes of secondary injuries:

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