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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Encouraging increased mobility: While mobility is important for overall health, it may not be the primary lifestyle modification emphasized in the discharge teaching for heart failure. The focus is typically on dietary and fluid restrictions, medication adherence, and symptom management.
B. Dietary and fluid restrictions: Dietary and fluid restrictions are essential lifestyle modifications for managing heart failure. Clients are often advised to follow a low-sodium diet and restrict fluid intake to prevent fluid retention and exacerbation of heart failure symptoms.
C. Cessation of intravenous (IV) drug use: While cessation of intravenous drug use is important for overall health and may be addressed if relevant to the client's situation, it may not be a primary focus of discharge teaching specifically related to heart failure.
D. Cessation of hormonal supplements: Cessation of hormonal supplements may be recommended if they contribute to heart failure or exacerbate its symptoms. However, this recommendation would be specific to individual client circumstances and may not apply to all clients with heart failure.
Correct Answer is A
Explanation
A. Decreased circulation to the kidneys: Post-cardiac arrest syndrome (PCAS) is a constellation of systemic ischemia/reperfusion injury responses that occur after return of spontaneous circulation (ROSC) following cardiac arrest. One of the manifestations of PCAS is decreased circulation to the kidneys due to the systemic hypoperfusion that occurs during cardiac arrest and the subsequent reperfusion injury that follows ROSC. This can lead to acute kidney injury (AKI) in some cases.
B. Increased mental capacity: While it is crucial to monitor neurological status after cardiac arrest, an immediate increase in mental capacity is not typically indicative of PCAS. Rather, neurological assessment may involve evaluating for signs of brain injury or dysfunction, which can include altered mental status, confusion, or neurological deficits.
C. Improving respiratory function: Improvement in respiratory function after cardiac arrest is a positive sign but may not necessarily indicate the development of PCAS. PCAS primarily involves systemic responses to the ischemia/reperfusion injury that occurs during and after cardiac arrest, rather than isolated respiratory changes.
D. Improvement in heart rate and blood pressure: Improvement in heart rate and blood pressure after cardiac arrest is generally expected with successful resuscitation efforts. However, these improvements alone may not necessarily indicate the development of PCAS. PCAS involves a broader range of systemic responses beyond just cardiac and hemodynamic changes.
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