A client had a traumatic brain injury from a bicycle accident 3 months ago. The client's partner states "Every few days I use a different approach to help them remember things but nothing seems to stick. The nurse's best reply is:

Have you tried videos or flash cards? People learn in different ways."

It is important to reinforce one consistent method due to the injury

Does he have a favorite type of music? Background music helps with memory

Maybe he is depressed due to the injury, Depression alters concentration”

Answer and Explanation

The Correct Answer is B

A. Have you tried videos or flash cards? People learn in different ways.: While videos or flashcards might be helpful tools for some, this response doesn't address the primary concern, which is consistency in the approach for memory recall. Reinforcing one method consistently is crucial for individuals with traumatic brain injuries (TBI) to help improve memory retention.

B. It is important to reinforce one consistent method due to the injury.: This is the best response. Individuals with brain injuries, especially those affecting memory, benefit from consistent, structured methods of learning and remembering. Changing the approach frequently can confuse the patient and hinder their progress. Reinforcing one method consistently will provide the brain with a routine to help it form connections and improve memory.

C. Does he have a favorite type of music? Background music helps with memory.: While music can sometimes be used in memory therapies, the suggestion of using music as background for memory enhancement is not a reliable or consistent approach. It doesn't address the need for a structured, consistent method that would be most beneficial in this case.

D. Maybe he is depressed due to the injury, Depression alters concentration.: While depression can affect cognitive functions such as concentration and memory, there is no direct indication in the partner’s statement that depression is the primary concern here. Focusing on consistent memory strategies is more appropriate as a first step.

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Correct Answer is C

Explanation

A. Decrease in blood pressure: Nitroglycerin can cause vasodilation, leading to a decrease in blood pressure. However, the goal of administering nitroglycerin during an acute myocardial infarction (MI) is not primarily to lower blood pressure, but to improve oxygen supply to the heart and relieve pain. A decrease in blood pressure may occur as a side effect but is not the primary indication for its use.

B. Decrease in cardiac dysrhythmias: While nitroglycerin may help reduce myocardial oxygen demand, it is not specifically aimed at treating or preventing cardiac dysrhythmias. The primary action of nitroglycerin is to relieve chest pain by vasodilation and improving blood flow to the heart muscle.

C. Relief of chest pain: The primary effect of nitroglycerin in the setting of an acute MI is to relieve chest pain (angina). It works by dilating coronary arteries and improving blood flow to the heart muscle, thus reducing ischemia and relieving pain.

D. Decrease in heart rate: Nitroglycerin may have a secondary effect of reducing heart rate due to a reduction in preload and afterload, but this is not the primary objective. Nitroglycerin’s main goal is to relieve chest pain by improving oxygen supply to the heart muscle.

A. who reports a change in pattern of their usual shortness of breath B. reports flank pain 7 on a (0-10) scale 15 min after getting an oral analgesic C. with serosanguinous drainage in a JP drain post op day 3. D. bilateral wheezes after walking 40 feet (12 meters), pulse ox 96 on RA

Correct Answer is A

Explanation

A. A change in the pattern of shortness of breath can be a sign of worsening respiratory or cardiovascular status and may indicate a serious condition such as pulmonary embolism, heart failure, or a pneumothorax. This requires immediate assessment and further investigation to determine the cause.

B. While flank pain (7/10) after receiving oral analgesic could be concerning, the fact that the pain is still significant 15 minutes after medication administration suggests that the pain may not yet be well-controlled. However, this is not as immediately urgent as a change in breathing pattern, so this patient should be assessed after the one with respiratory concerns.

C. Serosanguinous drainage from a JP drain on postoperative day 3 is not uncommon, and this typically does not require immediate intervention unless the drainage increases significantly or becomes more sanguine. This patient should be assessed after the one with a change in shortness of breath.

D. Bilateral wheezes after walking 40 feet, with a pulse oximetry of 96% on room air, is concerning but not as urgent as a change in shortness of breath. The pulse oximetry is within the normal range, and wheezing could be related to mild exertion or an underlying chronic condition (like asthma), but the patient’s condition doesn’t seem to be immediately life-threatening. This patient should be assessed after the patient with shortness of breath.

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A client had a traumatic brain injury from a bicycle accident 3 months ago. The client's partner states "Every few days I use a different approach to help them remember things but nothing seems to stick. The nurse's best reply is:

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