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. "I can't eat as much as I used to": While changes in eating habits may be related to various factors, such as appetite changes or difficulty chewing/swallowing, this statement does not specifically indicate how hearing loss affects the client's ability to perform ADLs.

B. "I get dizzy when I nod my head": This statement suggests that the client is experiencing dizziness, which could be related to hearing loss affecting their sense of balance. Dizziness can significantly impact the client's ability to perform activities of daily living (ADLs) safely, such as walking, cooking, or bathing, as it increases the risk of falls and injury.

C. "I wash my hair every other day": This statement describes a personal hygiene habit and does not directly indicate how hearing loss affects the client's ability to perform ADLs.

D. "I walk my dog at least twice a day": This statement describes an activity the client engages in and does not directly indicate how hearing loss affects the client's ability to perform ADLs. Walking a dog does not necessarily require hearing ability, as it primarily involves physical movement and visual observation.

A. "Your heart condition is caused by excessive stretching of the ventricles." B. "Your heart condition is caused from stiffening of the walls of the ventricles." C. "Your heart condition is caused by thickening of the ventricular walls and septum." D. "Your heart condition is caused when the ventricular tissue becomes fibrous and fatty."

Correct Answer is B

Explanation

A. "Your heart condition is caused by excessive stretching of the ventricles": This statement is incorrect. Excessive stretching of the ventricles typically occurs in dilated cardiomyopathy, not restrictive cardiomyopathy (RCM). In RCM, the primary issue is not excessive stretching but rather stiffening of the ventricular walls.

B. "Your heart condition is caused from stiffening of the walls of the ventricles": This statement is correct. Restrictive cardiomyopathy (RCM) is characterized by abnormal stiffening (fibrosis) of the ventricular walls, which impairs the heart's ability to fill properly during the diastolic phase of the cardiac cycle. This stiffening restricts the heart's ability to relax and fill with blood efficiently.

C. "Your heart condition is caused by thickening of the ventricular walls and septum": This statement describes hypertrophic cardiomyopathy (HCM), not restrictive cardiomyopathy (RCM). In HCM, there is abnormal thickening of the ventricular walls and septum, leading to impaired filling of the ventricles and potential obstruction of blood flow out of the heart.

D. "Your heart condition is caused when the ventricular tissue becomes fibrous and fatty": This statement describes arrhythmogenic right ventricular cardiomyopathy (ARVC), not restrictive cardiomyopathy (RCM). ARVC is characterized by replacement of myocardial tissue with fibrous and fatty tissue, primarily affecting the right ventricle.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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