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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 A

Explanation

Choice A Reason:

MS hug is appropriate. The "MS hug" is a colloquial term used to describe a sensation of tightness, pressure, or squeezing around the torso or chest area experienced by some individuals with multiple sclerosis (MS). It is caused by spasms or contractions of the intercostal muscles (muscles between the ribs) or the diaphragm due to lesions in the spinal cord disrupting nerve signals. This sensation can be uncomfortable or painful for the individual.

Choice B Reason:

Lhermitte's sign is inappropriate. Lhermitte's sign is a common symptom experienced by individuals with MS but it presents differently. It is characterized by an electric shock-like sensation that radiates down the spine and into the limbs, typically triggered by flexing the neck forward. It is caused by damage to the spinal cord's myelin sheath, leading to abnormal nerve signal transmission.

Choice C Reason:

Paroxysmal spasms is inappropriate. Paroxysmal spasms are sudden, involuntary muscle contractions or jerking movements that can occur in various parts of the body. While spasms are common in MS, they are not specifically associated with the sensation of tightness around the torso as described in the scenario.

Choice D Reason:

Trigeminal neuralgia is inappropriate. Trigeminal neuralgia is a condition characterized by sudden, severe facial pain often described as stabbing or electric shock-like. It is caused by irritation or damage to the trigeminal nerve, which is responsible for facial sensation. While individuals with MS may experience trigeminal neuralgia, it typically does not present with a tightening feeling around the torso.

A. Loss of teeth B. Stroke C. Sleepiness D. Fatty deposits E. Muscle dysfunction

Correct Answer is ["B","D","E"]

Explanation

Choice A Reason:

Loss of teeth is not typically considered a direct factor contributing to obstructive sleep apnea. While the presence of teeth may play a role in maintaining the structure of the oral cavity, it is not a primary risk factor for OSA.

Choice B Reason:

Stroke is correct. Individuals who have had a stroke are at increased risk of developing obstructive sleep apnea. Stroke can cause damage to areas of the brain involved in controlling breathing and upper airway function, leading to disruptions in respiratory control during sleep.

Choice C Reason:

Sleepiness is a symptom commonly associated with obstructive sleep apnea rather than a direct contributing factor. Excessive daytime sleepiness is a consequence of disrupted sleep patterns and recurrent episodes of breathing cessation during the night, which are characteristic features of obstructive sleep apnea.

Choice D Reason:

Fatty deposits is correct. Excessive fatty deposits, particularly around the neck and throat, can contribute to the narrowing and collapse of the upper airway during sleep, increasing the risk of obstructive sleep apnea. Obesity is a significant risk factor for OSA due to the accumulation of fat deposits in the upper airway tissues.

Choice E Reason:

Muscle dysfunction is correct. Muscle dysfunction, particularly of the muscles surrounding the upper airway, can impair the ability of these muscles to keep the airway open during sleep. Weakness or dysfunction of these muscles can lead to increased collapsibility of the upper airway, contributing to obstructive sleep apnea.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has multiple sclerosis and reports a tightening feeling around their torso. Which of the following conditions should the nurse recognize this finding indicates?

Correct Answer is A

Explanation

A nurse is discussing factors that can lead to obstructive sleep apnea with a group of older adults. Which of the following factors should the nurse include in the teaching? Select all that apply.Loss

Correct Answer is ["B","D","E"]

Explanation

A nurse is providing discharge instructions to a client who has epilepsy. Which of the following instructions should be included in the nurse's teaching? (Select All that Apply.)

A nurse is caring for a client who has a pulmonary embolism. The nurse should identify that the release of inflammatory mediators leads to which of the following pathologic findings?

A nurse is assessing a client who has tension pneumothorax. Which of the following findings should the nurse expect following tracheal deviation?

A nurse is teaching a group of student nurses about populations at higher risk for multiple sclerosis. Which of the following demographics should be included in the teaching? (Select All that Apply.)

A nurse is teaching a client who has a spinal cord injury about prevention of atelectasis. Which of the following statements should the nurse include in the teaching?

A nurse is caring for a client who has multiple sclerosis. Which of the following factors should the nurse anticipate have been identified as contributing to the development of multiple sclerosis? (Select All that Apply.)

A nurse is teaching a client who has a complete spinal cord injury about bowel and bladder management. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) (Select All that Apply.)

A client is seeking treatment for a respiratory infection at a local clinic. During the visit, the client verbalizes concern about the cost of medication and the inability to pay for it. Which of the following responses should the nurse use?