A nurse is caring for an adolescent client who was in a vehicle collision and has suffered a major head injury. The client's parents are considering organ donation and ask the nurse how the health care providers determine brain death. Which response by the nurse accurately describes brain death determination?

"Brain death has occurred if there is no spontaneous breathing or brainstem reflexes.

“If respiratory efforts cease and no apical pulse is audible, brain death is present."

"Brain death has occurred if a person has flaccid muscles and does not awaken.

“CPR does not restore a heartbeat; the brain cannot function."

Answer and Explanation

The Correct Answer is A

A. “Brain death has occurred if there is no spontaneous breathing or brainstem reflexes.” Brain death is defined as the irreversible cessation of all functions of the entire brain, including the brainstem. The absence of spontaneous breathing and brainstem reflexes (such as pupillary response, gag reflex, and eye movements) are critical criteria used to confirm brain death.

B. “If respiratory efforts cease and no apical pulse is audible, brain death is present.” While the cessation of respiratory efforts is a key component of brain death, the presence or absence of an apical pulse alone is not sufficient for determining brain death. Brain death is determined based on the complete absence of brain function, including brainstem reflexes.

C. “Brain death has occurred if a person has flaccid muscles and does not awaken.” Muscle flaccidity and lack of consciousness may be signs of severe brain injury, but they do not necessarily confirm brain death. Brain death is diagnosed based on the absence of brainstem reflexes and spontaneous breathing.

D. “CPR does not restore a heartbeat, the brain cannot function.” While it is true that CPR may not restore circulation in brain-dead patients, this statement is incomplete and not a precise definition of brain death. Brain death is determined by the irreversible cessation of all brain activity, not just by the failure of CPR to restore circulation.

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Correct Answer is A

Explanation

A. It indicates a normal depolarization of the atria: A PR interval of 0.12–0.20 seconds is within the normal range, representing normal conduction through the atria and AV node.

B. It provides information about atrial repolarization: Atrial repolarization is obscured by the QRS complex and not reflected in the PR interval.

C. It shows an early indication of first-degree heart block: First-degree heart block is indicated by a PR interval longer than 0.20 seconds.

D. It reflects a delayed conduction through the atria: A delay in conduction would result in a prolonged PR interval.

A. Intermittent claudication and pallor B. Jugular vein distention and dependent edema C. Diaphoresis and cool, clammy skin D. Mid-epigastric pain and heartburn

Correct Answer is C

Explanation

A. Intermittent claudication and pallor: These symptoms are more indicative of peripheral vascular disease, not a myocardial infarction.

B. Jugular vein distention and dependent edema. These symptoms suggest right-sided heart failure or fluid overload, not myocardial infarction.

C. Diaphoresis and cool, clammy skin. Diaphoresis (sweating) and cool, clammy skin are common signs of myocardial infarction due to the body's response to pain and decreased cardiac output.

D. Mid-epigastric pain and heartburn. While heartburn can mimic some symptoms of a heart attack, mid-epigastric pain and heartburn are more likely to be related to gastrointestinal issues rather than myocardial infarction.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is on cardiac telemetry monitoring and notes that the PR interval is 0.16 seconds. Which interpretation is correct for the nurse to make?

Correct Answer is A

Explanation

The nurse is caring for a client who reports persistent, crushing chest pain. What additional signs or symptoms would make a nurse suspect that the client is experiencing a myocardial infarction?

Correct Answer is C

Explanation

The nurse is caring for a client who is terminally and approaching the end of life. Which goal would the nurse identify as the priority?

Amlodipine (Norvasc) has been ordered for a client with newly diagnosed Prinzmetal's (variant) angina. The nurse knows the purpose of the amlodipine is to do which of the following?

A nurse is caring for an alert client who reports heart palpitations, nausea, and dizziness. An electrocardiogram (EKG) confirms the client is experiencing vector tachycardia (VT). The nurse should anticipate which action?

The nurse is caring for a client who has just had a pacemaker inserted. Which action should the nurse include in the initial plan of care?

The nurse has received a change-of-shift report on the following clients. Which client should the nurse see first?

The charge nurse is teaching a group of telemetry nurses about cardioversion. Which statement by the telemetry nurse would indicate that they understand the instruction about the electrical discharge?

The nurse is assessing a client with aortic stenosis. Which finding in the client's history would the nurse identify as the most common cause of this condition?