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

Assess palmar reflex.

Assess for cough reflex.

Assess the ability to follow simple commands.

Assess for Cushing's Triad.

Assess for abnormal posturing.

Answer and Explanation

Correct Answer : A,B,C,D,E

A. Assess palmar reflex. Assessing the palmar reflex helps evaluate the integrity of the nervous system, particularly in response to tactile stimuli. In clients with severe TBI, abnormal reflexes may indicate neurological impairment and guide further assessment and intervention.

B. Assess for cough reflex. Assessing the cough reflex is important for evaluating airway protection and the risk of aspiration, especially in clients with reduced consciousness level due to TBI.

C. Assess the ability to follow simple commands. Assessing the client's ability to follow simple commands provides valuable information about their level of consciousness and cognitive function. It helps determine the extent of neurological impairment and guides the plan of care, including interventions for communication and cognitive deficits.

D. Assess for Cushing's Triad. Cushing's Triad, characterized by hypertension, bradycardia, and irregular respirations, may occur as a late sign of increased intracranial pressure (ICP) in clients with severe TBI. Monitoring for Cushing's Triad is crucial for early recognition of elevated ICP and prompt intervention to prevent further neurological damage.

E. Assess for abnormal posturing. Assessing for abnormal posturing, such as decerebrate or decorticate posturing, helps evaluate neurological function and localize brain injury in clients with TBI. Abnormal posturing indicates severe brain damage and may guide decisions regarding treatment and prognostication.

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Correct Answer is ["A"]

Explanation

A. "I should not drive while taking this new medication."

Carvedilol is a beta blocker commonly prescribed for conditions like cardiomyopathy. One of the potential side effects of beta blockers, including carvedilol, is dizziness or drowsiness. These effects can occur, particularly when starting the medication or when the dosage is increased. Therefore, it's crucial for patients to understand that they may experience these symptoms and should avoid activities that require alertness, such as driving or operating heavy machinery, until they are aware of how the medication affects them. This precaution helps ensure their safety and the safety of others on the road.

B. "This new medication may decrease my sex drive."

Sexual dysfunction, including decreased libido or erectile dysfunction, is a recognized side effect of beta blockers like carvedilol. These medications can affect the autonomic nervous system and interfere with normal sexual function in some individuals. It's essential for patients to be aware of this potential side effect and to discuss any concerns with their healthcare provider. Open communication about sexual health can help address any issues that arise and explore alternative treatment options if necessary.

C. "This medication can make me have mood swings."

While mood changes are possible side effects of some medications, including certain classes of antidepressants or corticosteroids, they are not typically associated with beta blockers like carvedilol. Beta blockers primarily affect the cardiovascular system by blocking the effects of adrenaline, leading to decreased heart rate and blood pressure. While some patients may experience fatigue or depression as a side effect of beta blockers, mood swings are not a common manifestation. Therefore, this statement does not accurately reflect the potential side effects of carvedilol.

D. "I may have frequent hiccups while taking this medication."

While gastrointestinal side effects such as nausea, vomiting, or diarrhea are possible with carvedilol, frequent hiccups are not a commonly reported side effect of this medication. Hiccups, though often benign, can occasionally be bothersome or indicative of an underlying issue. However, they are not typically associated with beta blockers like carvedilol. Therefore, this statement does not accurately reflect the potential side effects of the medication.

E. "I may have urinary incontinence while taking this medication."

Urinary incontinence is a potential side effect of beta blockers like carvedilol. These medications can affect bladder function by relaxing the smooth muscle of the bladder and urethra, leading to urinary retention or incontinence in some individuals. Patients should be aware of this possibility and discuss any urinary symptoms with their healthcare provider. Depending on the severity of the symptoms, adjustments to the medication regimen or additional treatments may be necessary to manage urinary incontinence effectively.

A. Elevated erythrocyte sedimentation rate (ESR) B. Elevated thyroid-stimulating hormone (TSH) C. Elevated brain natriuretic peptide (BNP) D. Elevated C-reactive protein (CRP)

Correct Answer is B

Explanation

A. Elevated erythrocyte sedimentation rate (ESR): Elevated ESR indicates inflammation in the body and is not typically associated with the cause of atrial fibrillation.

B. Elevated thyroid-stimulating hormone (TSH): This is the correct answer. A common cause of atrial fibrillation is hyperthyroidism, which is characterized by an overactive thyroid gland and often presents with elevated TSH levels. Thyroid hormones play a significant role in regulating heart rate and rhythm. Excess thyroid hormone can lead to increased heart rate and irregular heart rhythms, including atrial fibrillation.

C. Elevated brain natriuretic peptide (BNP): Elevated BNP levels are associated with heart failure and may indicate cardiac stress or dysfunction. While heart failure can predispose individuals to atrial fibrillation, elevated BNP levels themselves are not a direct cause of atrial fibrillation.

D. Elevated C-reactive protein (CRP): Elevated CRP levels indicate inflammation in the body and are associated with various cardiovascular diseases. While inflammation can contribute to atrial fibrillation, elevated CRP levels alone are not a direct cause of atrial fibrillation.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has cardiomyopathy about the side effects of their new prescription beta blocker, carvedilol. Which of the following client statements should indicate to the nurse that the client understands the teaching? (select all that apply)

Correct Answer is ["A"]

Explanation

A nurse is reviewing laboratory results for a client who has atrial fibrillation. Which of the following blood test results should the nurse understand can be a possible cause of atrial fibrillation?

Correct Answer is B

Explanation

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