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 A

Explanation

A. Laminectomy: A laminectomy, while performed to relieve spinal nerve compression, may alter the biomechanics of the spine and lead to long-term instability. Over time, this can accelerate degeneration in adjacent spinal segments, increasing the risk for spinal stenosis recurrence or progression.
B. Hyperthyroidism: Hyperthyroidism affects metabolic rate and cardiovascular function but does not contribute to degenerative changes or structural narrowing of the spinal canal. It has no direct link to the development of spinal stenosis.
C. Hysterectomy: Although a hysterectomy may affect hormone levels, it has no anatomical relationship to the spine. It is not recognized as a contributing factor to the spinal canal narrowing seen in spinal stenosis.
D. Chronic obstructive pulmonary disease: COPD leads to respiratory impairment and reduced activity tolerance but is not associated with spinal degeneration. It does not cause the structural changes necessary for spinal stenosis to develop.

A. The glomerular filtration rate decreases because there is a reduction of blood flow to the kidneys. B. The glomerular filtration rate decreases because there is obstruction leading to the filtration system backing up and eventually shutting the kidneys down. C. The glomerular filtration rate decreases because inflammatory cells invade the already damaged kidneys D. The glomerular filtration rate decreases because there is injury to the renal tubular cells.

Correct Answer is D

Explanation

A. The glomerular filtration rate decreases because there is a reduction of blood flow to the kidneys:
Reduced renal perfusion causes prerenal acute kidney injury, not acute tubular necrosis (ATN). In ATN, the injury is intrarenal, specifically within the tubules, rather than being due to reduced blood flow to the kidneys.
B. The glomerular filtration rate decreases because there is obstruction leading to the filtration system backing up and eventually shutting the kidneys down: This describes postrenal acute kidney injury, typically due to obstruction in the urinary tract, such as stones or enlarged prostate. It is not the underlying mechanism in acute tubular necrosis, which is a type of intrarenal injury.
C. The glomerular filtration rate decreases because inflammatory cells invade the already damaged kidneys: While inflammation may be present in certain renal conditions, acute tubular necrosis primarily involves ischemic or toxic injury to tubular epithelial cells, not immune cell invasion. Inflammatory cell infiltration is more characteristic of interstitial nephritis.
D. The glomerular filtration rate decreases because there is injury to the renal tubular cells:
In acute tubular necrosis, the primary damage is to the tubular epithelial cells, leading to cellular death and sloughing. This impairs the kidney’s ability to reabsorb and filter properly, resulting in a drop in glomerular filtration rate due to tubular dysfunction and obstruction.

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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?

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