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 D

Explanation

A. "The heart and the coronary arteries weaken, leading to poor perfusion and resulting in angina": This statement is inaccurate. While angina can result from poor perfusion to the heart muscle, it is not typically due to weakening of the heart and coronary arteries. Angina often occurs due to coronary artery narrowing or blockage, leading to reduced blood flow and oxygen delivery to the myocardium.

B. "Coronary arteries become more elastic causing the arteries to stretch as individuals age causing the heart not to receive enough oxygen": This statement is incorrect. Coronary arteries do not become more elastic with age; in fact, they tend to become less elastic due to the development of atherosclerosis, which leads to arterial stiffening and decreased compliance. Atherosclerosis can cause narrowing or occlusion of the coronary arteries, resulting in reduced oxygen delivery to the heart muscle.

C. "Coronary arteries decrease in diameter leading to insufficient blood, oxygen, and nutrients reaching the heart muscle. Manifestations occur due to dilation of coronary arteries with increased blood flow causing increased pressure": This statement is partially incorrect. While it accurately describes the consequences of coronary artery narrowing (decrease in diameter) leading to insufficient blood, oxygen, and nutrient delivery to the heart muscle, the second part of the statement regarding dilation of coronary arteries with increased blood flow causing increased pressure is inaccurate. Coronary artery dilation is a compensatory response to increased demand for oxygen, aiming to improve blood flow to the myocardium. However, dilation alone does not increase pressure in the coronary arteries.

D. "Coronary arteries decrease in diameter leading to insufficient blood, oxygen, and nutrients reaching the heart muscle": This statement is accurate. Coronary artery disease (CAD) involves the progressive narrowing of the coronary arteries due to atherosclerosis, which reduces blood flow to the myocardium. As the arteries narrow, there is insufficient blood, oxygen, and nutrients reaching the heart muscle, leading to manifestations such as angina, myocardial ischemia, and potentially myocardial infarction.

A. Living a sedentary lifestyle B. Family history of atrial fibrillation C. History of thyroid disease D. Recent influenza infection

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

Explanation

All of the following should be included in the teaching:

A. Living a sedentary lifestyle: Sedentary behavior, characterized by physical inactivity, is a risk factor for various cardiovascular conditions, including atrial fibrillation. Regular exercise is important for maintaining heart health and reducing the risk of atrial fibrillation.

B. Family history of atrial fibrillation: A family history of atrial fibrillation increases an individual's risk of developing the condition. Genetic factors play a role in predisposing individuals to atrial fibrillation, and having a close relative with the condition can elevate one's risk.

C. History of thyroid disease: Thyroid disorders, particularly hyperthyroidism (overactive thyroid), are associated with an increased risk of atrial fibrillation. Thyroid hormones influence heart rate and rhythm, and imbalances can predispose individuals to atrial fibrillation.

D. Recent influenza infection: Infections, particularly respiratory infections such as influenza, can trigger episodes of atrial fibrillation in susceptible individuals. The inflammatory response and physiological stress associated with infections can disrupt normal heart rhythm and precipitate atrial fibrillation episodes.

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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.)

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Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has coronary artery disease. Which of the following statements should the nurse include in the teaching to explain the correlation between changes in the coronary arteries and manifestations that occur?

Correct Answer is D

Explanation

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?

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

Explanation

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