A nurse is caring for a client who has a traumatic brain injury. The client says to the nurse, "I don't remember what happened to me." How should the nurse respond?

"You have a brain injury that affects your memory."

"Don't worry, your memory will come back soon."

"What do you think happened to you?"

"Tell me more about how you feel right now."

Answer and Explanation

The Correct Answer is D

Choice A reason:

This is an incorrect answer. The nurse should not give information that might overwhelm or distress the client without assessing their readiness to learn.

Choice B reason:

This is an incorrect answer. The nurse should not give false reassurance or minimize the client's condition.

Choice C reason:

This is an incorrect answer. The nurse should not ask questions that might confuse or frustrate the client who has memory impairment.

Choice D reason:

This is a correct answer. The nurse should use therapeutic communication techniques such as exploring feelings, reflecting, and active listening to provide emotional support and establish rapport with the client.

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Correct Answer is C

Explanation

Choice A reason:

This is an incorrect answer. Elevated CSF protein level is a common finding in clients who have GBS due to demyelination of peripheral nerves. It does not indicate infection or inflammation and does not require immediate intervention.

Choice B reason:

This is an incorrect answer. Decreased serum CK level is a normal finding in clients who have GBS because CK is released from damaged muscle tissue and GBS does not affect muscle cells directly.

Choice C reason:

This is a correct answer. Increased CSF WBC count indicates infection or inflammation in the central nervous system (CNS), which can be a complication of GBS or a sign of another condition such as meningitis or encephalitis. The nurse should report this finding to the provider for further evaluation and treatment.

Choice D reason:

This is an incorrect answer. Decreased serum sodium level can occur.

A. Loss of sensation below the waist B. Paralysis of the lower extremities C. Impaired bladder and bowel control D. Difficulty swallowing E. Decreased sweating and shivering

Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason:

This is a correct answer. A spinal cord injury at the level of T6 affects the sensory nerves that innervate the lower half of the body, resulting in loss of sensation below the waist.

Choice B reason:

This is a correct answer. A spinal cord injury at the level of T6 affects the motor nerves that innervate the lower half of the body, resulting in paralysis of the lower extremities.

Choice C reason:

This is a correct answer. A spinal cord injury at the level of T6 affects the autonomic nerves that innervate the bladder and bowel, resulting in impaired bladder and bowel control.

Choice D reason:

This is an incorrect answer. A spinal cord injury at the level of T6 does not affect the cranial nerves that innervate the pharynx and esophagus, which are responsible for swallowing.

Choice E reason:

This is a correct answer. A spinal cord injury at the level of T6 affects the autonomic nerves that innervate the sweat glands and thermoregulatory centers, resulting in decreased sweating and shivering.

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A nurse is caring for a client who has a traumatic brain injury. The client says to the nurse, "I don't remember what happened to me." How should the nurse respond?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory results of a client who has Guillain-Barré syndrome (GBS). Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

A nurse is assessing a client who has a spinal cord injury at the level of T6. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

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