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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 D

Explanation

Choice A Reason:

Hypertension is not typically associated with heterotopic ossifications. However, it may occur in individuals with spinal cord injuries (SCI) due to autonomic dysreflexia, a condition characterized by an exaggerated sympathetic response to stimuli below the level of injury. Autonomic dysreflexia can lead to a sudden increase in blood pressure, which, if left untreated, can result in complications such as stroke or seizure. However, hypertension is not directly related to heterotopic ossifications.

Choice B Reason:

Bradycardia is also not typically associated with heterotopic ossifications. Like hypertension, bradycardia may occur in individuals with SCI due to autonomic dysreflexia. Autonomic dysreflexia can lead to a sudden increase in blood pressure and a reflex bradycardia in response to the increased sympathetic outflow. However, bradycardia is not directly related to heterotopic ossifications.

Choice C Reason:

Fecal impaction is a potential complication of spinal cord injury (SCI) due to impaired bowel function, but it is not directly related to heterotopic ossifications. SCI can disrupt normal bowel motility and result in neurogenic bowel dysfunction, leading to symptoms such as constipation, fecal impaction, and bowel obstruction. However, fecal impaction is not specific to heterotopic ossifications.

Choice D Reason:

Arthralgia is correct. Heterotopic ossifications (HO) involve the abnormal formation of bone in soft tissues around joints, muscles, tendons, or ligaments. When HO occurs around joints, it can lead to symptoms such as pain, swelling, and decreased range of motion, collectively known as arthralgia. Therefore, arthralgia is a common finding associated with heterotopic ossifications in individuals with spinal cord injuries.

A. Take small bites of food. B. Liquids should be thickened. C. Eat sitting slightly forward. D. Chew food thoroughly before swallowing. E. Avoid having conversations while eating. F. Avoid fiber in the diet.

Correct Answer is ["A","C","D"]

Explanation

Choice A Reason:

Take small bites of food is correct. Taking small bites of food can help prevent choking and aspiration, particularly during mealtime. It is a recommended practice for individuals with epilepsy to reduce the risk of aspiration if a seizure were to occur during eating.

Choice B Reason:

Liquids should be thickened is incorrect. Thickened liquids are typically recommended for individuals with swallowing difficulties (dysphagia) to help prevent aspiration. However, thickened liquids may not be necessary for all individuals with epilepsy unless specifically indicated based on their swallowing function assessment.

Choice C Reason:

Eat sitting slightly forward correct.: Eating while sitting slightly forward can help prevent aspiration in case of a seizure during meals. This position allows gravity to assist in preventing food or liquid from entering the airway.

Choice D Reason:

Chew food thoroughly before swallowing is correct. Thoroughly chewing food before swallowing is important for proper digestion and to reduce the risk of choking or aspiration, especially for individuals with epilepsy who may be at increased risk of aspiration during a seizure.

Choice E Reason:

Avoid having conversations while eating is incorrect. Avoiding conversations while eating is not directly related to epilepsy management. However, focusing on eating and taking appropriate precautions, such as sitting upright and chewing food thoroughly, can help reduce the risk of aspiration during meals.

Choice F Reason:

Avoid fiber in the diet is incorrect.: There is no specific recommendation to avoid fiber in the diet for individuals with epilepsy. In fact, a balanced diet that includes fiber-rich foods can promote overall health and well-being, which is important for individuals with epilepsy as well.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a spinal cord injury with heterotopic ossifications. Which of the following findings should the nurse expect?

Correct Answer is D

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.)

Correct Answer is ["A","C","D"]

Explanation

A nurse is providing discharge instruction to the family of a client who has Parkinson's disease and is a fall risk. Which of the following information should the nurse provide? (Select All that Apply.)

A nurse is caring for a client who has a spinal cord injury at the first thoracic level. Which of the following should the nurse recognize can trigger autonomic dysreflexia? (Select All that Apply.)

A nurse is providing teaching about potential complications to a client who has a spinal cord injury. Which of the following should the nurse include in the teaching as a common complication of spinal cord injuries? (Select All that Apply.)

A nurse is teaching a client who has a spinal cord injury about sexual stimulation. Which of the following statements by the nurse should be included in the teaching?

A nurse is caring for a group of clients in a medical unit. Which of the following clients is at the highest risk for developing osmotic cerebral edema?

A nurse is caring for a client who has a transection of the spinal cord at the level of cervical 7. Which of the following assessment findings should the nurse anticipate?

A nurse is assessing a client who has multiple sclerosis. The client reports that, since the onset of the disease, there are times when their symptoms are active and then followed by a period with no symptoms. Which of the following types of multiple sclerosis does this pattern indicate?

A nurse is providing care for a client who is at risk of cerebral aneurysm rupture. Which of the following interventions should the nurse include in the care plan?