A nurse is planning care for a client who has increased intracranial pressure. The nurse should understand that enteral nutrition should begin within 24 to 48 hr to help prevent which of the following complications?

Myocardial infarction

Bacterial translocation

Pulmonary embolus

Deep vein thrombosis

Answer and Explanation

The Correct Answer is B

A. Myocardial infarction: Enteral nutrition initiation within 24 to 48 hours is not directly associated with preventing myocardial infarction. While proper nutrition is important for overall cardiovascular health, the timing of enteral nutrition initiation primarily focuses on preventing complications related to increased intracranial pressure (ICP).

B. Bacterial translocation: Initiating enteral nutrition within 24 to 48 hours in clients with increased intracranial pressure helps prevent complications such as bacterial translocation. Bacterial translocation refers to the passage of bacteria from the gastrointestinal tract into the bloodstream and systemic circulation. Delayed initiation of enteral nutrition can lead to intestinal mucosal breakdown and increased intestinal permeability, facilitating bacterial translocation. Early enteral nutrition helps maintain intestinal mucosal integrity, reduces gut bacterial overgrowth, and decreases the risk of bacterial translocation, thereby lowering the risk of infectious complications.

C. Pulmonary embolus: Initiating enteral nutrition within 24 to 48 hours is not directly associated with preventing pulmonary embolus. Pulmonary embolism is a complication characterized by the obstruction of pulmonary arteries by blood clots, typically originating from deep vein thrombosis. Prevention of pulmonary embolus involves measures such as early mobilization, pharmacological prophylaxis, and mechanical compression devices to prevent venous stasis and thrombus formation.

D. Deep vein thrombosis: Initiating enteral nutrition within 24 to 48 hours is not directly associated with preventing deep vein thrombosis. Deep vein thrombosis is a complication characterized by the formation of blood clots within deep veins, commonly in the lower extremities. Prevention of deep vein thrombosis involves measures such as early mobilization, pharmacological prophylaxis, and mechanical compression devices to prevent venous stasis and thrombus formation.

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Correct Answer is B

Explanation

A. Female sex: While gender can influence the risk of certain health conditions, such as cardiovascular diseases, there isn't a direct correlation between being female and an increased risk of delirium. Both males and females can develop delirium under certain circumstances.

B. History of drug and alcohol use: A history of drug and alcohol use increases the risk for the development of delirium. Substance abuse, including alcohol, illicit drugs, and certain prescription medications, can disrupt neurotransmitter function and lead to alterations in mental status, including delirium. Additionally, withdrawal from alcohol or drugs can precipitate delirium in susceptible individuals.

C. Lack of medical insurance: While access to healthcare and socioeconomic factors can impact overall health outcomes, there isn't a direct association between lack of medical insurance and an increased risk of delirium. Delirium is more closely linked to medical conditions, substance use, and other physiological factors.

D. History of lymphoma: While certain medical conditions, such as infections, metabolic disturbances, and neurological disorders, can increase the risk of delirium, there isn't a direct correlation between a history of lymphoma and the development of delirium. Delirium is more commonly associated with acute illness, surgery, or medication use.

A. "My vision is blurry and objects are hazy." B. "l can't see anything in the middle part of my eyes." C. "There are dark spots moving around in my eye." D. "l can't see objects from the sides of my eyes."

Correct Answer is B

Explanation

A. Severe myopia: Severe myopia refers to nearsightedness and is not typically associated with Meniere's disease. Myopia affects vision but is unrelated to the characteristic symptoms of Meniere's disease.

B. Vertigo: Vertigo is a hallmark symptom of Meniere's disease. It is characterized by a sensation of spinning or dizziness, often accompanied by nausea, vomiting, and imbalance. Vertigo episodes in Meniere's disease can be severe and debilitating, significantly impacting the individual's quality of life.

C. Anosmia: Anosmia refers to a loss of sense of smell and is not a typical manifestation of Meniere's disease. Meniere's disease primarily affects the inner ear and is characterized by symptoms related to vestibular dysfunction, such as vertigo, rather than olfactory disturbances.

D. Photopsia: Photopsia refers to the perception of flashing lights or visual disturbances and is not a characteristic manifestation of Meniere's disease. Visual disturbances may occur in certain conditions affecting the eyes or visual pathways but are not typically associated with Meniere's disease, which primarily affects the inner ear and vestibular system.

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A nurse is planning care for a client who has increased intracranial pressure. The nurse should understand that enteral nutrition should begin within 24 to 48 hr to help prevent which of the following complications?

Nursing Test Bank

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Correct Answer is B

Explanation

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