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 C

Explanation

A. "Distributive shock occurs due to loss of myocardial contractility": This statement is incorrect. Distributive shock is not primarily caused by loss of myocardial contractility. Instead, distributive shock is characterized by widespread vasodilation, which leads to inadequate tissue perfusion despite normal or high cardiac output.

B. "Distributive shock occurs due to loss of blood volume": This statement is inaccurate. Distributive shock is not primarily caused by loss of blood volume. While hypovolemia (loss of blood volume) can lead to shock, distributive shock specifically involves excessive vasodilation, resulting in a relative hypovolemia due to pooling of blood in the expanded vascular bed.

C. "Distributive shock occurs due to systemic vasodilation": This statement is correct. Distributive shock, also known as vasodilatory shock, occurs due to widespread vasodilation of the systemic vasculature. This vasodilation leads to a decrease in systemic vascular resistance, which results in the redistribution of blood flow away from vital organs and tissues, leading to inadequate tissue perfusion and shock.

D. "Distributive shock occurs due to increased systemic vascular resistance": This statement is incorrect. Distributive shock is characterized by decreased systemic vascular resistance due to vasodilation, not increased systemic vascular resistance. Increased systemic vascular resistance is more commonly associated with conditions such as hypertension or obstructive shock.

A. Falls B. Violence C. Sports-related injuries D. Working as a firefighter E. Working in a factory

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

Explanation

Answer: A, B, and C

Rationale: A) Falls: Falls are a leading cause of traumatic brain injuries (TBIs) across all age groups, especially among older adults and young children. Falls can occur due to various factors such as slipping, tripping, or accidents from heights.

B) Violence: Acts of violence, including assaults, gunshot wounds, and domestic abuse, are significant contributors to TBIs. These traumatic events can result in head injuries with varying degrees of severity, depending on the force and nature of the trauma.

C) Sports-related injuries: Participation in contact sports or activities with a risk of collision or impact, such as football, soccer, or cycling, can lead to TBIs. Athletes may experience concussions or more severe head injuries during games or practice sessions.

D) Working as a firefighter: While occupations like firefighting can expose individuals to hazardous situations, including fires and building collapses, they are not typically cited as primary causes of TBIs. However, firefighters may face head injury risks while performing their duties, especially during rescue operations or structural collapses.

E) Working in a factory: While accidents in industrial settings can lead to various injuries, including head trauma, they are not among the primary causes of TBIs. However, workers in factories or industrial environments may face risks associated with machinery accidents, falling objects, or workplace incidents.

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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 and a newly licensed nurse are providing care for a client who has distributive shock. How should the nurse explain the pathophysiology of distributive shock to the newly licensed nurse?

Correct Answer is C

Explanation

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

Explanation

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