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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "The ability to insert an endotracheal tube": This competency refers to technical skills in airway management, not to addressing cultural concerns or preferences in care. The ability to insert an endotracheal tube is a skill that does not directly relate to the scenario of cultural sensitivity.
B. "The ability to precept another nurse": While precepting may involve teaching or guiding others, the discussion of gender preferences for care is related to cultural competency and collaboration in a healthcare setting, rather than mentoring another nurse.
C. "The ability to collaborate as a team member.": The scenario described highlights the need for the nurse to work with the provider and the client to address cultural concerns and ensure that the client feels comfortable with their care. Collaboration with the healthcare team is a key competency in providing culturally sensitive care.
D. "The ability to act as charge nurse" Being a charge nurse involves managing a team, but it is not specifically relevant to addressing the client's preferences regarding the gender of the provider. This issue is more about cultural competence and collaboration than charge nurse responsibilities.
Correct Answer is C
Explanation
A. An accumulation of fluid in the pericardial space leads to hardening of the cardiac ventricles: Cardiac tamponade is characterized by fluid accumulation in the pericardial space, which compresses the heart, preventing it from expanding fully. Hardening of the ventricles is not a primary feature of this condition.
B. Additional fluid collects in the pericardial space and systemic venous pressure decreases: In fact, as fluid accumulates in the pericardial space, systemic venous pressure actually increases because the heart struggles to pump blood effectively due to the compression.
C. Rapid accumulation of fluid around the heart causes hemodynamic changes to occur: The rapid buildup of fluid in the pericardium places pressure on the heart, causing significant hemodynamic changes like decreased cardiac output, which can result in shock.
D. Pericardial fluid accumulation causes life-threatening circulatory failure: Although fluid accumulation in the pericardium can lead to circulatory failure, this is a more general statement. The immediate concern is the hemodynamic changes (such as reduced stroke volume and compromised cardiac output) that result from the fluid buildup.
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