A nurse is caring for a client in the intensive care unit who suddenly becomes confused and agitated. The nurse recognizes these manifestations are likely related to a condition with which of the following characteristics?

Isolated

permanent

Reversible

Unique

Answer and Explanation

The Correct Answer is C

A. Isolated: This term refers to something that is separate or distinct. Confusion and agitation in a client are not typically isolated but can be part of a broader clinical picture.

B. Permanent: These manifestations are not typically permanent and can often be reversed with appropriate interventions.

C. Reversible: Confusion and agitation in a client are often reversible and can be due to various factors such as medications, infections, metabolic disturbances, or other medical conditions. Identifying and addressing the underlying cause can often restore the client to their baseline mental status.

D. Unique: While every individual's presentation may have unique aspects, confusion and agitation are not considered unique manifestations in the context of acute changes in mental status. They are common symptoms that can occur due to a variety of reasons and are not exclusive to any particular condition.

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Correct Answer is A

Explanation

A. Loss of sensation and cognition difficulties: Secondary conditions commonly associated with traumatic brain injury (TBI) include sensory impairments such as loss of sensation, as well as cognitive difficulties such as memory loss, attention deficits, and impaired executive functioning. These issues arise due to the damage to brain tissue caused by the initial injury and can have significant impacts on the client's overall function and quality of life.

B. Development of emotional disorders and acute pain : While emotional disorders such as depression, anxiety, and post-traumatic stress disorder (PTSD) are common following TBI, acute pain is not typically considered a primary secondary condition associated with TBI. Chronic pain may develop as a secondary condition, but acute pain is more often associated with the immediate aftermath of the injury.

C. Body dysmorphia and neurofibrillary tangles : Body dysmorphia, a condition characterized by obsessive preoccupation with perceived flaws in physical appearance, and neurofibrillary tangles, abnormal protein aggregates found in the brains of individuals with neurodegenerative disorders such as Alzheimer's disease, are not typically associated with TBI.

D. Decreased appetite and a lack of sleep : While changes in appetite and sleep disturbances may occur as secondary symptoms of TBI, they are not as commonly anticipated as loss of sensation and cognition difficulties. These issues may arise due to disruptions in brain function or changes in lifestyle following the injury.

A. "Note if you see any flashing bright lights on the grid." B. "Check to see if the lines on the grid are blurry or distorted." C. "Monitor for the lines on the grid to change in color or brightness." D. "Watch for floating dark spots on the grid."

Correct Answer is B

Explanation

A. "Note if you see any flashing bright lights on the grid." Flashing lights are not typically associated with macular degeneration. This symptom is more commonly associated with conditions like retinal detachment or migraine headaches.

B. "Check to see if the lines on the grid are blurry or distorted." This statement is correct. The Amsler grid is used to detect changes in central vision, which are common in macular degeneration. Patients with macular degeneration may perceive wavy or distorted lines instead of straight lines when looking at the grid, indicating central vision loss.

C. "Monitor for the lines on the grid to change in color or brightness." Changes in color or brightness of the lines on the grid are not typical features of macular degeneration. This statement does not accurately reflect the purpose of using an Amsler grid for macular degeneration.

D. "Watch for floating dark spots on the grid." Floating dark spots (floaters) are not typically associated with macular degeneration. Floaters are more commonly associated with conditions like posterior vitreous detachment or retinal detachment.

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A nurse is caring for a client in the intensive care unit who suddenly becomes confused and agitated. The nurse recognizes these manifestations are likely related to a condition with which of the following characteristics?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a traumatic brain injury (TBI). Which of the following secondary conditions should the nurse anticipate the client might develop?

Correct Answer is A

Explanation

A nurse is teaching a client who has macular degeneration about how to use an Amsler grid. Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who has a subarachnoid hemorrhage and asks why they are having a CT angiography. Which of the following should the nurse understand about CT angiography?

A nurse is planning care for a client who has suspected cardiac tamponade. Which of the following diagnostic tests should the nurse anticipate the provider to order first?

A nurse is evaluating the plan of care during a postoperative visit for a client who had a retinal reattachment procedure. Which of the following statements indicates the client is following the instructions in the plan of care?

A nurse is preparing a poster about chronic traumatic encephalopathy (CTE) for a local community health fair. Which of the following activities should the nurse include on the poster as increasing the risk for CTE?

The nurse is assisting with planning care for a client who has a subarachnoid hemorrhage (SAH). Which of the following relates to a high mortality rate for a client who has an SAH?

A nurse is teaching the caregiver of a client who has dementia. Which of the following behaviors should the nurse identify as increasing with the progression of the disorder? (Select All that Apply.)

A nurse is planning care for a client who has a traumatic brain injury (TBI). Which of the following nursing interventions should be added to the plan of care? (Select All that Apply.)

A nurse is reinforcing teaching to a group of high school students about how penetrating traumatic brain injuries cause damage to the brain. Which of the following statements should the nurse include in the teaching?