A nurse is caring for a client who has a traumatic brain injury and is being mechanically ventilated. Which of the following can cause unfavorable outcomes for this client?

Hyperoxia

Platelet count 250,000/mm^3

Hemoglobin 16 g/dL

Glasgow Coma Scale 16

Answer and Explanation

The Correct Answer is A

Choice A rationale

Hyperoxia, or high oxygen levels, can cause unfavorable outcomes for a client who has a traumatic brain injury and is being mechanically ventilated. Too much oxygen can lead to oxygen toxicity and cause damage to the lungs and other organs, including the brain.
Choice B rationale
A platelet count of 250,000/mm^3 is within the normal range and would not typically cause unfavorable outcomes for a client who has a traumatic brain injury and is being mechanically ventilated.
Choice C rationale
A hemoglobin level of 16 g/dL is within the normal range and would not typically cause unfavorable outcomes for a client who has a traumatic brain injury and is being mechanically ventilated.
Choice D rationale
A Glasgow Coma Scale score of 16 is not possible as the maximum score is 15. A higher score indicates a less severe injury, so it would not typically cause unfavorable outcomes for a client who has a traumatic brain injury and is being mechanically ventilated.

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Correct Answer is B

Explanation

Choice A rationale
Pulmonary embolus is a serious condition that can occur due to prolonged immobility, but it is not directly related to the timing of enteral nutrition in a client with increased intracranial pressure.

Choice B rationale
Bacterial translocation refers to the migration of bacteria from the gut to other areas of the body. Early enteral nutrition (within 24 to 48 hours) in critically ill patients can help maintain the integrity of the gut mucosa and prevent bacterial translocation. Therefore, starting enteral nutrition within this timeframe can help prevent bacterial translocation.
Choice C rationale
Deep vein thrombosis, like pulmonary embolus, is a risk due to immobility but is not directly related to the timing of enteral nutrition.
Choice D rationale
Myocardial infarction is a cardiac event that could be related to overall cardiovascular health, stress, or specific injury to the cardiac muscle. It is not directly prevented by the initiation of enteral nutrition.

A. Brainstem ischemia B. Tachycardia C. Agonal breathing D. Chest pain

Correct Answer is A

Explanation

Choice A rationale
Cushing’s Triad, which includes bradycardia (low heart rate), irregular respiration, and widened pulse pressure, is a nervous system response that could prevent brainstem ischemia. Brainstem ischemia is a condition where there is insufficient blood flow to the brainstem, which can lead to cell death.
Choice B rationale

While tachycardia (high heart rate) is a serious condition, it is not typically prevented by Cushing’s Triad.
Choice C rationale
Agonal breathing, which is characterized by gasping, labored breathing, particularly when lying flat, is not typically prevented by Cushing’s Triad.
Choice D rationale
Chest pain is not typically prevented by Cushing’s Triad. Cushing’s Triad is a response to increased intracranial pressure, not a cardiac condition.

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A nurse is caring for a client who has a traumatic brain injury and is being mechanically ventilated. Which of the following can cause unfavorable outcomes for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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