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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Pelvic fracture: Pelvic fractures may cause significant pain and instability but do not typically result in a shortened, adducted, and externally rotated leg.

B. Femoral neck fracture: These findings (shortened, adducted, externally rotated leg) are classic for a femoral neck fracture due to muscle contraction and displacement of the bone.

C. Tibia fracture: Tibia fractures typically present with swelling and deformity, not shortening or rotation of the leg.

D. Fibula fracture: A fibula fracture alone rarely causes leg shortening or rotation as it is a non-weight-bearing bone.

A. Troponin B. Alkaline phosphatase C. Creatine kinase D. Myoglobin

Correct Answer is A

Explanation

A. Troponin: Troponin is the most specific and reliable biomarker for myocardial injury. Levels rise within 3-6 hours and remain elevated for days, providing diagnostic and prognostic information.

B. Alkaline phosphatase: This is related to liver and bone disorders, not cardiac events.

C. Creatine kinase (CK): While CK-MB is specific to cardiac tissue, it is less specific and remains elevated for a shorter period compared to troponin.

D. Myoglobin: Myoglobin is an early but nonspecific marker of muscle damage and is not as reliable for diagnosing myocardial injury.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client and find their right leg is shortened, adducted and externally rotated. These assessment findings would indicate which type of injury?

Correct Answer is B

Explanation

The nurse is caring for a client who is newly admitted with severe chest pain and suspected myocardial infarction. Which diagnostic blood test would be considered the most reliable and critical indicator of myocardial injury?

Correct Answer is A

Explanation

The health care provider prescribes IV mannitol for a client with an intracranial pressure (ICP) of 22. How will the nurse determine that the medication had the intended effect?

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?

The nurse is preparing a client for an electrophysiology procedure. What statements would the nurse include when explaining this procedure to a client? Select All That Apply

The nurse is caring for a client with sinus bradycardia. The nurse understands that this arrhythmia may be caused by which of the following? Select All That Apply

The patient is asymptomatic but is diagnosed with second-degree heart block Mobitz 1. The patient is on digoxin at home. Which of the following interventions will the nurse anticipate?

The nurse is assessing a brain-injured client response to nail bed pressure. The client demonstrates internal rotation, adduction, and flexion of the arms, the nurse should report the response as which finding

The nurse is assigned to the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first?

A client is being seen in the clinic to rule out mitral valve stenosis. Which assessment data would be an early indication of this condition?