A nurse is teaching a group of nursing students about brain herniation. Which of the following interventions should the nurse include as a possible treatment for brain herniation?

Decrease sedation.

Hyperventilate the client.

Lower blood pressure.

Reduce the temperature in the room.

Answer and Explanation

The Correct Answer is B

A. Decrease sedation: Decreasing sedation may help reduce intracranial pressure (ICP) by allowing the client to have a more responsive level of consciousness. However, it is not a direct treatment for brain herniation. Sedation reduction should be done cautiously to prevent agitation and further increases in ICP.

B. Hyperventilate the client: Hyperventilation is a temporary intervention used to reduce intracranial pressure by inducing cerebral vasoconstriction, which decreases cerebral blood flow and intracranial volume. However, it is typically reserved for acute situations and is not considered a definitive treatment for brain herniation. Prolonged or excessive hyperventilation can lead to cerebral ischemia and should be used cautiously.

C. Lower blood pressure: Lowering blood pressure may help reduce cerebral perfusion pressure, which can mitigate the risk of further brain injury during herniation. However, lowering blood pressure alone is not a direct treatment for brain herniation. It may be part of the overall management strategy to prevent secondary injury.

D. Reduce the temperature in the room: Reducing the temperature in the room, or therapeutic hypothermia, is sometimes used in the management of elevated intracranial pressure and brain injury. Lowering body temperature can reduce metabolic demands and cerebral edema, thereby lowering intracranial pressure. However, it is not a direct treatment for brain herniation and should be implemented cautiously to prevent complications such as shivering and hypotension.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A) "Pentoxifylline can be administered to help the platelets from sticking together and occluding the vessels": Pentoxifylline is a medication used to improve blood flow by decreasing the viscosity of blood. However, it is not typically used to treat mitral valve stenosis. This statement does not accurately reflect treatment options for this condition.

B) "A heparin bolus is administered and followed with a continuous infusion to help keep the blood thinner": Heparin is an anticoagulant used to prevent blood clot formation, but it is not a treatment for mitral valve stenosis itself. While anticoagulants may be used in certain situations with mitral valve stenosis (such as in the setting of atrial fibrillation), they do not directly address the underlying valve narrowing.

C) "A flexible catheter will be inserted into a vessel of the arm, neck, or groin and advanced to the heart to dilate a narrowed or occluded artery": This statement describes a procedure known as percutaneous transluminal mitral valvuloplasty (PTMV), which is a minimally invasive intervention used to treat mitral valve stenosis. During this procedure, a catheter with a deflated balloon on its tip is inserted into a vessel and guided to the heart, where the balloon is inflated to widen the narrowed valve.

D) "A small catheter with a balloon on the end is threaded into a vessel in the groin and advanced to the heart where the balloon will be inflated, and the narrowed valve will be dilated": This statement accurately describes balloon valvuloplasty, which is a common procedure used to treat mitral valve stenosis. By inflating the balloon within the narrowed valve, the procedure aims to widen the valve opening, thus improving blood flow through the heart.

A. Loss of sensation and cognition difficulties B. Development of emotional disorders and acute pain C. Body dysmorphia and neurofibrillary tangles D. Decreased appetite and a lack of sleep

Correct Answer is A

Explanation

A. Loss of sensation and cognition difficulties: Secondary conditions commonly associated with traumatic brain injury (TBI) include sensory impairments such as loss of sensation, as well as cognitive difficulties such as memory loss, attention deficits, and impaired executive functioning. These issues arise due to the damage to brain tissue caused by the initial injury and can have significant impacts on the client's overall function and quality of life.

B. Development of emotional disorders and acute pain : While emotional disorders such as depression, anxiety, and post-traumatic stress disorder (PTSD) are common following TBI, acute pain is not typically considered a primary secondary condition associated with TBI. Chronic pain may develop as a secondary condition, but acute pain is more often associated with the immediate aftermath of the injury.

C. Body dysmorphia and neurofibrillary tangles : Body dysmorphia, a condition characterized by obsessive preoccupation with perceived flaws in physical appearance, and neurofibrillary tangles, abnormal protein aggregates found in the brains of individuals with neurodegenerative disorders such as Alzheimer's disease, are not typically associated with TBI.

D. Decreased appetite and a lack of sleep : While changes in appetite and sleep disturbances may occur as secondary symptoms of TBI, they are not as commonly anticipated as loss of sensation and cognition difficulties. These issues may arise due to disruptions in brain function or changes in lifestyle following the injury.

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A nurse is teaching a group of nursing students about brain herniation. Which of the following interventions should the nurse include as a possible treatment for brain herniation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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