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.

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Correct Answer is C

Explanation

A. "Distributive shock occurs due to loss of myocardial contractility": This statement is incorrect. Distributive shock is not primarily caused by loss of myocardial contractility. Instead, distributive shock is characterized by widespread vasodilation, which leads to inadequate tissue perfusion despite normal or high cardiac output.

B. "Distributive shock occurs due to loss of blood volume": This statement is inaccurate. Distributive shock is not primarily caused by loss of blood volume. While hypovolemia (loss of blood volume) can lead to shock, distributive shock specifically involves excessive vasodilation, resulting in a relative hypovolemia due to pooling of blood in the expanded vascular bed.

C. "Distributive shock occurs due to systemic vasodilation": This statement is correct. Distributive shock, also known as vasodilatory shock, occurs due to widespread vasodilation of the systemic vasculature. This vasodilation leads to a decrease in systemic vascular resistance, which results in the redistribution of blood flow away from vital organs and tissues, leading to inadequate tissue perfusion and shock.

D. "Distributive shock occurs due to increased systemic vascular resistance": This statement is incorrect. Distributive shock is characterized by decreased systemic vascular resistance due to vasodilation, not increased systemic vascular resistance. Increased systemic vascular resistance is more commonly associated with conditions such as hypertension or obstructive shock.

A. Tonometer intraocular pressure reading 8 mm Hg B. Smooth retina edges identified on slit-lamp biomicroscope examination C. Visual acuity of 20/20 using the Snellen eye chart D. Lens and cornea appear intact during ophthalmoscope exam

Correct Answer is A

Explanation

Tonometer intraocular pressure reading 8 mm Hg (Option A): A low intraocular pressure reading may indicate a detached retina. In a detached retina, the vitreous humor (gel-like substance in the eye) may leak into the space behind the retina, causing a decrease in intraocular pressure. However, it's important to note that intraocular pressure alone cannot definitively diagnose a detached retina, and further diagnostic tests, such as a dilated eye examination or retinal imaging, would be needed for confirmation.

Smooth retina edges identified on slit-lamp biomicroscope examination (Option B): In the case of a detached retina, the edges of the retina may appear irregular or undulating rather than smooth. This irregularity is often observed during a dilated eye examination rather than with a slit-lamp biomicroscope.

Visual acuity of 20/20 using the Snellen eye chart (Option C): Visual acuity may be affected in a detached retina, depending on the extent and location of the detachment. However, visual acuity alone cannot confirm a detached retina, as other factors such as refractive errors or cataracts can also affect visual acuity.

Lens and cornea appear intact during ophthalmoscope exam (Option D): While a detached retina may be visualized during an ophthalmoscope examination as a gray or whitish area behind the lens, the appearance of the lens and cornea being intact does not definitively diagnose a detached retina. A thorough dilated eye examination by an ophthalmologist is necessary for accurate diagnosis.

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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

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Correct Answer is A

Explanation

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