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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Smoking tobacco is the primary and most significant risk factor for emphysema. Tobacco smoke contains harmful chemicals and toxins that directly damage the lungs. Chronic exposure to cigarette smoke leads to inflammation and destruction of lung tissue, particularly the alveoli, contributing to the development of emphysema.
Choice B Reason:
Between 20 to 30 years of age. While smoking at any age is harmful to lung health, the risk of developing emphysema increases with prolonged exposure to tobacco smoke over many years. Emphysema is typically a disease of middle to older age, with symptoms often appearing after years of smoking.
Choice C Reason:
Asthma is a chronic inflammatory condition of the airways characterized by reversible airflow obstruction and airway hyperresponsiveness. While asthma and emphysema are both respiratory diseases, they have distinct pathophysiological mechanisms and risk factors. Asthma is not a direct cause of emphysema, although some individuals with poorly controlled asthma may develop chronic obstructive pulmonary disease (COPD), which includes emphysema as one of its components.
Choice D Reason:
Pollution is not correct. Environmental pollution, including air pollution from industrial emissions, vehicle exhaust, and particulate matter, can contribute to respiratory problems and exacerbate pre-existing lung conditions. While exposure to pollution can worsen respiratory symptoms and lung function, it is not the primary cause of emphysema. However, long-term exposure to certain pollutants may increase the risk of developing respiratory diseases, including COPD, which encompasses emphysema.
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.
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