A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse include in the plan?

Administer opioids.

Darken the room.

Apply restraints.

Reduce stimuli.

Answer and Explanation

The Correct Answer is D

Choice A Reason: This is incorrect. Opioids are not indicated for a client who is emerging from a coma, as they can cause respiratory depression, sedation, and confusion. They may also mask the signs of increased intracranial pressure or neurological deterioration.

Choice B Reason: This is incorrect. Darkening the room may not be helpful for a client who is emerging from a coma, as it may increase their disorientation and agitation. The nurse should provide adequate lighting and orient the client to time, place, and person frequently.

Choice C Reason: This is incorrect. Applying restraints may worsen the restlessness and agitation of a client who is emerging from a coma, as they may perceive them as a threat or a restriction. Restraints may also increase the risk of injury, infection, or skin breakdown. The nurse should use restraints only as a last resort and with a physician's order.

Choice D Reason: This is correct. Reducing stimuli is an appropriate intervention for a client who is emerging from a coma, as it can help calm them and prevent sensory overload. The nurse should limit noise, visitors, and unnecessary procedures, and provide a quiet and comfortable environment.

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Correct Answer is B

Explanation

Choice a) is incorrect because calcium levels are not directly aﬀected by hemodialysis. Calcium is a mineral that is important for bone health, blood clotting, and muscle contraction. Hemodialysis does not remove calcium from the blood, but it may cause low calcium levels if the dialysate ﬂuid has a lower concentration of calcium than the blood.

Choice b) is correct because potassium levels are decreased by hemodialysis. Potassium is an electrolyte that is essential for nerve and muscle function, especially the heart. Hemodialysis removes excess potassium from the blood, which can build up in people with kidney failure and cause irregular heartbeats, muscle weakness, or even cardiac arrest.

Choice c) is incorrect because protein levels are not decreased by hemodialysis. Protein is a macromolecule that is composed of amino acids and performs various functions in the body, such as building and repairing tissues, transporting substances, and regulating processes. Hemodialysis does not remove protein from the blood, but it may cause low protein levels if the client has a poor diet or loses protein through other means, such as urine or wounds.

Choice d) is incorrect because RBC count is not decreased by hemodialysis. RBCs are red blood cells that carry oxygen throughout the body. Hemodialysis does not remove RBCs from the blood, but it may cause low RBC count if the client has anemia, which is a common complication of kidney failure. Anemia can be caused by reduced production of erythropoietin (a hormone that stimulates RBC production), iron deficiency, or blood loss.

A. Troponin is an enzyme that indicates damage to brain, heart, and skeletal muscle tissues. B. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. C. Troponin is a protein that helps transport oxygen throughout the body. D. Troponin is a lipid whose levels reﬂect the risk for coronary artery disease.

Correct Answer is B

Explanation

Choice a) is incorrect because troponin is not an enzyme, but a protein. Enzymes are molecules that speed up chemical reactions in the body. Troponin does not have this function.

Choice b) is correct because troponin is a protein that binds to calcium and regulates the contraction of heart muscle fibers. When the heart muscle is injured, such as in a myocardial infarction, troponin leaks into the bloodstream and can be detected by a blood test. The higher the level of troponin, the more severe the damage to the heart.

Choice c) is incorrect because troponin does not help transport oxygen throughout the body. That function is performed by hemoglobin, which is a protein found in red blood cells.

Choice d) is incorrect because troponin is not a lipid, but a protein. Lipids are fats that are used for energy storage and cell membrane formation. Troponin does not have these roles.

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A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory data of a client following a hemodialysis treatment. The nurse should expect to find a decrease in which of the following laboratory values?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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