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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","F"]
Explanation
Choice A rationale
Patients with poorly controlled diabetes, such as those experiencing diabetic ketoacidosis (DKA), are at an increased risk of developing peripheral neuropathy. High blood sugar levels can damage peripheral nerves over time.
Choice B rationale
Sleep apnea is not typically associated with an increased risk of developing peripheral neuropathy.
Choice C rationale
While hypertension can lead to a variety of health complications, it is not typically associated with an increased risk of developing peripheral neuropathy.
Choice D rationale
Systemic Lupus Erythematosus (SLE) is an autoimmune disease that can affect the nervous system, including the peripheral nerves, leading to peripheral neuropathy.
Choice E rationale
Untreated tuberculosis is not typically associated with an increased risk of developing peripheral neuropathy.
Choice F rationale
Chronic alcohol use can lead to nutritional deficiencies, particularly of the B vitamins, which are essential for nerve health. This can result in peripheral neuropathy.
Correct Answer is C
Explanation
Choice A rationale
Trigeminal neuralgia is a chronic pain condition that affects the trigeminal nerve, which carries sensation from your face to your brain. It does not cause a sensation of tightness around the torso.
Choice B rationale
Lhermitte’s sign is a symptom of multiple sclerosis and other neurological conditions where a person feels an electric shock-like sensation running down the spine and into the limbs. It does not cause a sensation of tightness around the torso.
Choice C rationale
The sensation of tightness around the torso in a patient with multiple sclerosis is often referred to as the “MS hug”. It is caused by a lesion or an area of active inflammation within the spinal cord.
Choice D rationale
Paroxysmal spasms are a type of muscle spasm experienced by some people with multiple sclerosis. These spasms are usually painful and involve the muscles of the legs, but they do not cause a sensation of tightness around the torso.
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