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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Rheumatoid arthritis: Rheumatoid arthritis is an autoimmune condition characterized by chronic inflammation of the joints. Some research suggests a possible link between autoimmune disorders such as rheumatoid arthritis and Meniere's disease. Autoimmune conditions can affect the inner ear, leading to vestibular dysfunction and contributing to the development of Meniere's disease.

B. Bacterial pneumonia: Bacterial pneumonia is a respiratory infection caused by bacterial pathogens. There is no direct association between bacterial pneumonia and an increased risk of developing Meniere's disease. Meniere's disease primarily affects the inner ear and is not related to respiratory infections.

C. Macular degeneration: Macular degeneration is a degenerative eye disease that affects the central portion of the retina. There is no known association between macular degeneration and an increased risk of developing Meniere's disease. These conditions affect different parts of the body and are not related in terms of etiology or risk factors.

D. Osteoporosis: Osteoporosis is a condition characterized by loss of bone density, leading to an increased risk of fractures. There is no direct association between osteoporosis and an increased risk of developing Meniere's disease. These conditions affect different systems in the body and are not known to be related.

A. Apply soft restraints to wrists and chest. B. Administer antipsychotic medications as prescribed. C. Administer sedative medications as prescribed. D. Arrange for one-on-one observation for the client.

Correct Answer is D

Explanation

A. Apply soft restraints to wrists and chest: Using restraints should only be considered as a last resort and should not be the first intervention for managing delirium. Restraints can exacerbate agitation and increase the risk of complications such as skin breakdown, musculoskeletal injury, and psychological distress. Therefore, applying restraints should not be the first action taken by the nurse.

B. Administer antipsychotic medications as prescribed: While antipsychotic medications may be used to manage symptoms of delirium in some cases, they should not be the first intervention for preventing client injury. Additionally, the use of antipsychotics in the ICU requires careful consideration due to potential adverse effects, such as sedation, hypotension, and prolongation of the QT interval. The decision to administer antipsychotic medications should be based on a comprehensive assessment and in consultation with the healthcare team.

C. Administer sedative medications as prescribed: Administering sedative medications may help calm an agitated client with delirium, but it should not be the first intervention for preventing client injury. Sedatives can further impair cognition and increase the risk of falls or other complications. Like antipsychotic medications, the use of sedatives should be based on a thorough assessment and in collaboration with the healthcare team, rather than being the initial action taken by the nurse.

D. Arrange for one-on-one observation for the client: Delirium in the intensive care unit (ICU) is a serious condition that can lead to confusion, disorientation, and an increased risk of injury to the client. The priority intervention for preventing client injury in this situation is to ensure constant monitoring and supervision. By arranging for one-on-one observation, the nurse can provide continuous monitoring of the client's behavior, assess for changes or signs of agitation, and intervene promptly to prevent falls or other injuries.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 about health conditions that increase the risk for developing Meniere’s disease. Which of the following factors should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is providing care for a client who has delirium in the intensive care unit. Which of the following interventions should the nurse implement first to prevent client injury?

Correct Answer is D

Explanation

A nurse is providing care for a group of clients who have coronary artery disease who are all scheduled for coronary artery bypass grafts (CABG). Which of the following clients is at the highest risk for complications following the surgical procedure?

A nurse is planning care for a client who has worsening heart failure and is experiencing arrhythmias. Which of the following procedures should the nurse anticipate the client will require to regulate the rhythm?

A nurse is teaching a group of clients about risk factors for developing atrial flutter. Which of the following clients should the nurse understand is at highest risk for developing atrial flutter?

A nurse is teaching a client who has arrhythmogenic cardiomyopathy about the risk for sudden cardiac death. Which of the following client statements indicates to the nurse an understanding of the teaching?

A nurse is teaching a group of clients about risk factors for developing atrial fibrillation. Which of the following should be included in the teaching?

A nurse is providing discharge teaching to a client who has heart failure. Which of the following lifestyle modifications should the nurse include in the discharge teaching?

A nurse is providing CPR to a client. Which of the following aspects of CPR are different in the community versus in the hospital? (Select All that Apply.)

A nurse is teaching a client who has pericarditis. Which of the following statements should the nurse include in the client teaching to explain the cause of pericarditis?