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
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 C
Explanation
Choice A rationale
While improved rehabilitation outcomes and temporary behavior changes can occur after a neurological injury, they are not typically considered psychosocial changes. Psychosocial changes often involve alterations in the way individuals perceive, interact with, and navigate their social environments.
Choice B rationale
Improved mood stability and temper control are not typically associated with the aftermath of a neurological injury. In fact, individuals may experience mood swings, irritability, and difficulties with emotional regulation.
Choice C rationale
Changes to social cognition and challenges to inhibitory control are indeed possible psychosocial changes a client might have after sustaining a neurological injury. Social cognition involves understanding and interpreting social cues, which can be affected by brain injury.
Challenges to inhibitory control can lead to impulsive behavior and difficulties in social situations.
Choice D rationale
While a sense of purpose, improved motivation, and stable relationships can be part of a successful recovery process, they are not typically direct outcomes of a neurological injury. In
fact, relationships may be strained and motivation can be affected due to the physical and emotional challenges associated with such an injury.
Correct Answer is D
Explanation
Choice A rationale
Regulation of the amount of carbon dioxide exhaled can affect cerebral blood flow, but it does not directly maintain cerebral perfusion pressure constant.
Choice B rationale
Catecholamines circulating throughout the body can affect blood pressure and heart rate, but they do not directly maintain cerebral perfusion pressure constant.
Choice C rationale
How much blood is pumped from the heart, also known as cardiac output, can affect cerebral perfusion pressure. However, it does not directly maintain cerebral perfusion pressure constant.
Choice D rationale
Regulation of constriction and dilation of blood vessels in the brain, also known as cerebral autoregulation, is a key mechanism that maintains cerebral perfusion pressure constant. When pressure autoregulation is impaired, cerebral blood flow becomes dependent on cerebral perfusion pressure.
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