A nurse is planning care for a client who has a mild traumatic brain injury (TBI). Which of the following should the nurse include in the plan of care?

Response to noxious stimuli

Obstructive sleep apnea

Trousseau's sign

Cranial nerve assessment

Answer and Explanation

The Correct Answer is D

A. Response to noxious stimuli: While assessing the response to noxious stimuli can be an important part of neurological assessment, it is not specific to mild traumatic brain injury (TBI). The primary focus should be on cranial nerve assessment to evaluate brain function and detect any early signs of deterioration.
B. Obstructive sleep apnea: Obstructive sleep apnea is not a typical concern for a client with mild TBI. The focus should be on the immediate effects of the injury, such as cranial nerve function, rather than conditions unrelated to the head injury.
C. Trousseau's sign: Trousseau's sign is a test used to assess for latent tetany (muscle spasms), typically in cases of hypocalcemia. It is not relevant for a client with mild TBI unless there are other symptoms indicating electrolyte imbalances, which are not the primary concern in this case.
D. Cranial nerve assessment: Cranial nerve assessment is a key part of evaluating the neurological status of a client with mild TBI. It helps identify any deficits or changes in brain function that may indicate deterioration or more severe injury. This should be part of the plan of care for a mild TBI client.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Anxiety, unintended weight loss, palpitations: These symptoms are consistent with hyperthyroidism, where excess thyroid hormone speeds up metabolism. Hyperthyroidism is typically associated with low TSH levels due to negative feedback suppression of the pituitary gland.
B. Fatigue, constipation, weight gain: These are classic symptoms of hypothyroidism, where a deficiency of thyroid hormones slows metabolic processes. An elevated TSH level reflects the pituitary's response to low circulating thyroid hormone, attempting to stimulate the thyroid to produce more.
C. Increased thirst, increased urine output, and weight loss: These symptoms point to hyperglycemia or conditions like diabetes mellitus, not thyroid dysfunction. They are due to glucose imbalances rather than altered thyroid hormone or TSH levels.
D. Shakiness, sweating, nausea: These symptoms are typically seen in hypoglycemia or acute adrenal issues, where blood glucose or cortisol levels drop. They do not correspond with thyroid hormone imbalances or elevated TSH.

A. Serum sodium 140 mg/dL B. Blood urea nitrogen (BUN) 18 mg/dL C. Serum bicarbonate less than 15 D. Arterial blood pH 7.46

Correct Answer is C

Explanation

A. Serum sodium 140 mg/dL: This is a normal sodium level and does not provide diagnostic information specific to DKA. Sodium may fluctuate in DKA but is not a defining lab value for the condition.
B. Blood urea nitrogen (BUN) 18 mg/dL: This BUN level is within normal limits. Although BUN can be elevated in DKA due to dehydration, a normal value does not support the diagnosis of DKA on its own.
C. Serum bicarbonate less than 15: A low bicarbonate level indicates metabolic acidosis, which is a key diagnostic feature of DKA. It reflects the buffering of excess ketone acids in the blood, making this a highly specific indicator.
D. Arterial blood pH 7.46: This value is slightly alkalotic and inconsistent with DKA, which is characterized by metabolic acidosis and a pH usually below 7.3. Elevated pH would suggest another acid-base disorder.

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A nurse is planning care for a client who has a mild traumatic brain injury (TBI). Which of the following should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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