A nurse is caring for a client who had a traumatic brain injury (TBI). Which of the following manifestations indicate a mild TBI?

Persistent headache and aggression

Headache and confusion

Loss of vision and depression

Seizures and extremity weakness

Answer and Explanation

The Correct Answer is B

A. Persistent headache and aggression: While persistent headache and aggression can occur following a traumatic brain injury (TBI), these symptoms are not specific to mild TBI. Aggression is more commonly associated with severe TBI, and persistent headache can occur across the spectrum of TBI severity.

B. Headache and confusion: Headache and confusion are common manifestations of mild TBI. Following a mild TBI, individuals often experience headache, which may be mild to moderate in intensity. Confusion, disorientation, and difficulty concentrating are also typical symptoms of mild TBI due to the transient disruption of cognitive function.

C. Loss of vision and depression: Loss of vision and depression are less commonly associated with mild TBI. These manifestations may occur in more severe cases of TBI or with specific types of brain injury affecting visual pathways. However, they are not typically indicative of mild TBI.

D. Seizures and extremity weakness: Seizures and extremity weakness are more indicative of moderate to severe TBI rather than mild TBI. While mild TBI may result in brief loss of consciousness, seizures and significant extremity weakness are less characteristic of mild TBI and are more commonly observed with more severe brain injuries.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Lie on your back when sleeping: Lying on the back when sleeping may be recommended initially after cochlear implant surgery to avoid putting pressure on the surgical site. However, this instruction should not be included in the plan of care indefinitely. Once the client is comfortable and the surgical site is healing well, they should be allowed to sleep in any position that is comfortable for them.

B. Lie on your front when sleeping: Lying on the front when sleeping is not typically recommended after cochlear implant surgery, as it may put pressure on the surgical site and disrupt healing. This position could potentially cause discomfort and increase the risk of complications. Therefore, this instruction should not be included in the plan of care.

C. Resume your exercise routine: Resuming the exercise routine immediately after cochlear implant surgery may not be advisable. The client should be instructed to avoid strenuous activities and heavy lifting for a certain period as advised by the healthcare provider. Engaging in vigorous exercise too soon after surgery could potentially disrupt the healing process and increase the risk of complications. Therefore, this instruction should not be included in the plan of care immediately after surgery.

D. Wash your hair 24 hr after surgery: After cochlear implant insertion, it is important to keep the surgical site clean to prevent infection. Washing the hair 24 hours after surgery helps to maintain cleanliness and hygiene without disrupting the surgical site. It is typically safe to wash the hair after this period as long as gentle care is taken to avoid excessive manipulation of the implant site.

A. Completing hourly endotracheal suctioning B. Ensuring proper ventriculostomy transducer levels C. Monitoring volume status D. Elevating the head of the bed 15°

Correct Answer is D

Explanation

A. Completing hourly endotracheal suctioning: Hourly endotracheal suctioning is not typically indicated for a client with increased intracranial pressure (ICP). Frequent suctioning can lead to increased intrathoracic pressure and potentially compromise venous return, which may further elevate ICP. Suctioning should be performed as needed to maintain airway patency while minimizing the risk of increasing ICP.

B. Ensuring proper ventriculostomy transducer levels: Ensuring proper ventriculostomy transducer levels is important for accurate measurement of intracranial pressure (ICP) but may not directly alleviate elevated ICP. Monitoring ICP through ventriculostomy allows for timely detection of changes in ICP, which can guide interventions to manage elevated pressure levels. However, it is not a direct intervention to reduce ICP.

C. Monitoring volume status: Monitoring volume status is important in managing a client with increased intracranial pressure (ICP) as both hypovolemia and hypervolemia can impact ICP. However, monitoring volume status alone does not directly address elevated ICP. Interventions to optimize volume status, such as fluid administration or diuresis, may be implemented based on assessment findings, but they should be done cautiously to avoid exacerbating cerebral edema or altering cerebral perfusion.

D. Elevating the head of the bed 15°: Elevating the head of the bed 15° (or higher) is a crucial intervention for managing a client with increased intracranial pressure (ICP). This position helps promote venous drainage from the brain, reducing venous congestion and intracranial pressure. Elevating the head of the bed also helps prevent cerebrospinal fluid (CSF) from pooling in the brain, which can further increase ICP. Placing the client in a semi-upright position is a standard practice in managing ICP and is recommended in various clinical guidelines.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who had a traumatic brain injury (TBI). Which of the following manifestations indicate a mild TBI?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a plan of care for a client who is postoperative following a cochlear implant insertion. Which of the following instructions should the nurse include in the plan of care?

Correct Answer is D

Explanation

A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse plan to include in the plan of care?

Correct Answer is D

Explanation

A nurse is planning care for a client who has suspected cardiac tamponade. Which of the following diagnostic tests should the nurse anticipate the provider to order first?

A nurse is assessing a client who reports manifestations of tinnitus. Which of the following actions should the nurse perform to determine if movement is causing the clients manifestations to worsen?

A nurse is teaching a group of clients about risk factors for developing hypertrophic cardiomyopathy (HCM). Which of the following clients should the nurse understand is most at risk for developing HCM?

A nurse is teaching a client who has restrictive cardiomyopathy (RCM). Which of the following statements should the nurse include in the client teaching to explain the cause of RCM?

A nurse is planning care for a client who has increased intracranial pressure. The nurse should understand that enteral nutrition should begin within 24 to 48 hr to help prevent which of the following complications?

A nurse is reviewing laboratory results for a client who has pericarditis. Which of the following blood test results should the nurse anticipate? (Select All that Apply.)

A nurse is educating the family of a client who has Alzheimer's disease. The nurse should be sure to communicate that which of the following behavioral manifestations can occur in clients with Alzheimer’s disease? (Select All that Apply.)