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 A

Explanation

Choice A rationale
The aura phase is characterized by sensory, motor, or visual disturbances that occur before the headache phase of a migraine. Symptoms such as tingling of the face and blind spots in the eyes are common during this phase.

Choice B rationale
The postdrome phase, also known as the “migraine hangover,” occurs after the headache phase. It does not typically include symptoms such as tingling of the face or blind spots in the eyes.
Choice C rationale
The prodrome phase, also known as the pre-headache phase, can occur hours to days before the headache phase. It can include symptoms such as mood changes, food cravings, and neck stiffness, but not typically tingling of the face or blind spots in the eyes.
Choice D rationale
The headache phase is the period during a migraine when the actual headache occurs. It is not typically associated with symptoms such as tingling of the face or blind spots in the eyes.

A. Rebleeding of the injury B. Decreased cerebrospinal fluid C. Use of nimodipine D. Poor functional ability

Correct Answer is A

Explanation

Choice A rationale
Rebleeding of the injury is a significant factor related to a high mortality rate for a client who has a subarachnoid hemorrhage (SAH). SAH is a devastating event with substantial mortality and high morbidity among survivors. The most common primary causes of death or neurological devastation leading to withdrawal of support are direct effects of the primary hemorrhage (55%) and aneurysm rebleeding (17%)2. Therefore, rebleeding of the injury is a critical concern in the management of SAH.
Choice B rationale
Decreased cerebrospinal fluid is not directly linked to a high mortality rate in SAH. While changes in cerebrospinal fluid dynamics can occur after SAH, it’s not typically a primary factor contributing to mortality.
Choice C rationale
The use of nimodipine is actually part of the treatment protocol for SAH. Nimodipine is a calcium channel blocker that is used to prevent cerebral vasospasm, a complication of SAH. It does not contribute to a higher mortality rate.
Choice D rationale
Poor functional ability could be a result of SAH due to neurological damage, but it is not a direct cause of high mortality. The severity of the initial hemorrhage and subsequent

complications like rebleeding or medical complications are more directly tied to mortality rates.

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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 patient with a history of migraines comes into the clinic reporting “tingling of the face and blind spots in the eyes.”. Which of the following phases of a migraine is the patient experiencing?

Correct Answer is A

Explanation

The nurse is assisting with planning care for a client who has a subarachnoid hemorrhage (SAH). Which of the following relates to a high mortality rate for a client who has an SAH?

Correct Answer is A

Explanation

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