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","C","D","E"]
Explanation
Choice A Reason:
Decreased visual acuity is correct. Yes, decreased visual acuity, including issues such as poor depth perception, reduced peripheral vision, and difficulty with contrast sensitivity, can contribute to falls and head injuries in older adults.
Choice B Reason:
Motor vehicle crashes is incorrect. While motor vehicle crashes can cause head injuries in individuals of all ages, they are less common among older adults compared to younger age groups.
Choice C Reason:
Polypharmacy is correct. Yes, polypharmacy, which refers to the use of multiple medications concurrently, is a common risk factor for falls and head injuries in older adults. Certain medications, especially those with sedative or psychotropic effects, can increase the risk of falls and accidents.
Choice D Reason:
Weakness is correct. Yes, weakness, frailty, and decreased muscle strength are common age-related changes that can increase the risk of falls and subsequent head injuries in older adults.
Choice E Reason:
Chronic hypertension, particularly when poorly controlled, can contribute to an increased risk of falls in older adults through various mechanisms:Hypertension medications or the condition itself can lead to orthostatic hypotension. This can cause dizziness or lightheadedness, increasing the risk of falls.Chronic hypertension is a major risk factor for cerebrovascular disease, including strokes. These events can lead to neurological deficits such as weakness, numbness, or impaired balance, predisposing individuals to falls.
Choice F Reason:
Previous military experience is incorrect. While previous military experience may contribute to certain health conditions or injuries in older adults, it is not a common reason for head injuries specifically related to falls or accidents in this population.
Correct Answer is B
Explanation
Choice A Reason:
Flail chest is incorrect. Flail chest is a condition characterized by multiple rib fractures, causing instability in the chest wall. While it can lead to respiratory distress, it doesn't directly cause ventilation-perfusion (V/Q) mismatch. Instead, it impairs the mechanics of breathing by compromising chest wall integrity.
Choice B Reason:
Emphysema is a chronic obstructive pulmonary disease (COPD) where the alveolar walls are destroyed, leading to a loss of surface area for gas exchange. This results in areas of the lungs that are well-perfused but poorly ventilated, causing a V/Q mismatch. The damage to alveoli leads to impaired ventilation, while blood flow may still be adequate, leading to hypoxemia (low oxygen levels in the blood).
Choice C Reason:
CHF primarily affects the heart’s ability to pump blood effectively, leading to pulmonary congestion and impaired gas exchange. However, it typically causes diffusion defects rather than a direct ventilation-perfusion mismatch. V/Q mismatch may occur secondary to pulmonary edema, but it’s not the primary mechanism of respiratory failure in CHF.
Choice D Reason:
Guillain-Barré syndrome is incorrect. Guillain-Barré syndrome (GBS) is a neurological disorder that affects the peripheral nervous system, leading to muscle weakness and paralysis. While respiratory muscle weakness can occur in GBS, it doesn't directly cause ventilation-perfusion (V/Q) mismatch. GBS primarily affects nerve function rather than lung function.
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