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A nurse is caring for a client in the intensive care unit who was admitted with severe head trauma and cerebral edema. The client opens their eyes spontaneously, is oriented, and obeys commands. Which of the following findings indicate the client is experiencing a decline in their condition?
(Select All that Apply.)

Client responds to name

Eyes open to painful stimuli

Client states day of the week

Client is confused

Client mumbles inappropriate words

Eyes do not open to name

Answer and Explanation

Correct Answer : B,D,E,F

Choice A Reason:

Client responds to name is incorrect. Responding to one's name is a positive sign indicating consciousness and orientation. It suggests that the client's level of consciousness is relatively intact.

Choice B Reason:

Eyes open to painful stimuli is correct. Opening the eyes in response to painful stimuli is a concerning sign, indicating a decrease in consciousness and potentially worsening neurological status. It suggests that the client's level of arousal is diminishing and may indicate a decline in condition.

Choice C Reason:

Client states day of the week is correct. Oriented behavior, such as knowing the day of the week, is a positive sign indicating intact cognition and orientation. It suggests that the client's mental status is relatively preserved.

Choice D Reason:

Client is confused is correct. Confusion is a concerning sign, indicating altered mental status and potentially worsening neurological function. It suggests that the client's cognition is impaired, which may be indicative of a decline in condition.

Choice E Reason:

Client mumbles inappropriate words is correct. Mumbling inappropriate words suggests disorientation and altered mental status, which are concerning signs indicating a decline in neurological function.

Choice F Reason:

Eyes do not open to name is incorrect. Failure to open the eyes in response to verbal stimuli, such as one's name, is a concerning sign indicating a decrease in consciousness and potentially worsening neurological status. It suggests that the client's level of arousal is diminished and may indicate a decline in condition.

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Correct Answer is B

Explanation

Choice A Reason:

Flying itself is not typically considered a factor that worsens MS manifestations. However, factors related to flying, such as stress, fatigue, changes in routine, and potential exposure to infections, may contribute to symptom exacerbation in some individuals with MS.

Choice B Reason:

Sunbathing is appropriate. Exposure to excessive heat, such as sunbathing or prolonged exposure to hot weather, can lead to temporary worsening of MS symptoms, a phenomenon known as Uhthoff's phenomenon. Increased body temperature can temporarily impair nerve conduction in individuals with MS, resulting in exacerbation of symptoms such as fatigue, weakness, sensory disturbances, and cognitive impairment.

Choice C Reason:

Working in an office is inappropriate. Working in an office environment is not inherently associated with exacerbation of MS manifestations. However, factors such as stress, fatigue, poor ergonomic conditions, and limited mobility during prolonged periods of sitting may contribute to symptom exacerbation in some individuals with MS.

Choice D Reason:

High altitude travel is inappropriate. High altitude travel can exacerbate MS symptoms due to the decreased oxygen levels and potential changes in barometric pressure at high altitudes. Hypoxia (low oxygen levels) at high altitudes may exacerbate fatigue, weakness, and cognitive impairment in individuals with MS. Changes in barometric pressure can also trigger or worsen symptoms such as headaches, sensory disturbances, and balance problems in some individuals with MS.

A. The client should maintain systolic BP between 120 and 129 mm Hg. B. The client should maintain systolic BP between 136 and 140 mm Hg. C. The client should maintain systolic BP between 141 and 145 mm Hg. D. The client should maintain systolic BP between 130 and 135 mm Hg.

Correct Answer is A

Explanation

Choice A Reason:

The client should maintain systolic BP between 120 and 129 mm Hg. This option aligns with current guidelines for blood pressure management following a transient ischemic attack (TIA). Tight blood pressure control is recommended to reduce the risk of recurrent cerebrovascular events, such as stroke. Maintaining systolic blood pressure (SBP) between 120 and 129 mm Hg has been associated with significant risk reduction in stroke recurrence compared to higher blood pressure targets. Therefore, this option reflects the recommended approach for blood pressure management in individuals with a history of TIA.

Choice B Reason:

The client should maintain systolic BP between 136 and 140 mm Hg: This option suggests a systolic blood pressure (SBP) range that is higher than the recommended target for blood pressure management following a TIA. Allowing SBP to remain in the range of 136 to 140 mm Hg may pose an increased risk of recurrent cerebrovascular events compared to tighter blood pressure control.

Choice C Reason:

The client should maintain systolic BP between 141 and 145 mm Hg. Similarly, this option proposes a systolic blood pressure (SBP) range that is higher than the recommended target for blood pressure management following a TIA. Allowing SBP to remain in the range of 141 to 145 mm Hg may not provide adequate protection against stroke recurrence compared to tighter blood pressure control.

Choice D Reason:

The client should maintain systolic BP between 130 and 135 mm Hg. While this option suggests a systolic blood pressure (SBP) range that is closer to the recommended target compared to options B and C, it still falls slightly above the optimal range for blood pressure management following a TIA. Tighter blood pressure control, ideally below 130 mm Hg, is typically preferred to reduce the risk of recurrent cerebrovascular events.

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Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has multiple sclerosis about factors that can worsen their manifestations. Which of the following factors should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is providing discharge instruction to a client who has hypertension that has resulted in a transient ischemic attack (TIA). Which of the following information should the nurse discuss with the client regarding blood pressure (BP) management?

Correct Answer is A

Explanation

A nurse is caring for a client who was involved in a motor vehicle accident. The client is alert and oriented and reports a loss of consciousness immediately after the accident. Which of the following additional manifestations should the nurse assess the client for? (Select All that Apply.)

A nurse is assessing a client who has multiple sclerosis. Which of the following assessment findings should the nurse anticipate? (Select All that Apply.)

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A client who has a history of migraines reports to a clinic with a throbbing headache. Which of the following questions should the nurse include in the assessment? (Select All that Apply.)

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A nurse is assisting with the plan of care for a client who has a spinal cord injury and spasm-induced incontinence. Which of the following medications should the nurse anticipate a prescription for?

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