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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Correct Answer is ["A","C","D"]

Explanation

A. Take small bites of food: Taking small bites of food is important for clients with Parkinson's disease to reduce the risk of choking and aspiration. It allows better control of swallowing and reduces the likelihood of difficulty swallowing, which is common in Parkinson’s disease due to dysphagia (swallowing difficulty).
B. Liquids should be thickened: While thickening liquids is often recommended for clients with swallowing difficulties, it is not universally required for all Parkinson's patients. It would depend on the specific swallowing assessment and the client’s condition. Therefore, this is not an essential recommendation for every client.
C. Sit slightly forward when eating: Sitting slightly forward helps clients with Parkinson's disease improve their swallowing and reduce the risk of aspiration. This posture encourages a safer swallowing reflex and reduces the likelihood of food or liquids going into the airway.
D. Chew food thoroughly before swallowing: Thoroughly chewing food is vital for clients with Parkinson’s disease because it reduces the risk of choking and aspiration. This allows the food to break down into smaller pieces, making it easier to swallow and less likely to cause blockages in the throat.
E. Avoid having conversations while eating: While it is important to focus on eating to prevent choking, there is no strict guideline that clients with Parkinson’s must avoid conversation entirely. Talking while eating may be challenging for some, but it is not universally harmful. However, the client should be reminded to focus on swallowing to prevent aspiration.

A. "Yes, antiviral treatment will ensure that you are less contagious and do not spread influenza to others." B. "No, you should wait for lab confirmation because taking antivirals for a nonviral infection can increase side effects." C. Yes, antiviral treatments are most effective when they are started within 48 hours of symptom onset." D. "No, you should wait for lab confirmation before beginning antiviral treatment, to prevent resistant viruses"

Correct Answer is C

Explanation

A. "Yes, antiviral treatment will ensure that you are less contagious and do not spread influenza to others": While antiviral treatment can reduce the spread of influenza, it is not the primary reason for early initiation. The key reason for starting antiviral therapy early is to reduce the severity and duration of symptoms.
B. "No, you should wait for lab confirmation because taking antivirals for a nonviral infection can increase side effects": This is incorrect because antivirals for influenza are specific to the virus and are not used in non-viral infections. Delaying treatment could worsen symptoms.
C. "Yes, antiviral treatments are most effective when they are started within 48 hours of symptom onset": This is the most accurate statement. Antiviral drugs like oseltamivir (Tamiflu) are most effective when taken early, within the first 48 hours of symptom onset, to reduce symptom severity and duration.
D. "No, you should wait for lab confirmation before beginning antiviral treatment, to prevent resistant viruses": Early treatment is essential, and delaying therapy can lead to worsened symptoms or complications. Resistance is a concern, but it is not an immediate issue with influenza antivirals.

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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

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Correct Answer is ["A","C","D"]

Explanation

Correct Answer is C

Explanation

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