A client is admitted to the intensive care unit (ICU) with a traumatic brain injury. Which invasive procedure should the nurse anticipate preparing the client to undergo?

Tracheostomy placement

Central line insertion

Nasogastric tube (NGT) insertion

Pacemaker placement

Answer and Explanation

The Correct Answer is C

Choice A reason: Tracheostomy placement is for prolonged airway management, not immediate in traumatic brain injury (TBI). NGT insertion addresses acute needs like gastric decompression or feeding, as TBI may impair swallowing, making this procedure less urgent than managing intracranial complications.

Choice B reason: Central line insertion provides vascular access but is not specific to TBI. NGT insertion prevents aspiration or manages gastric contents, critical in TBI with altered consciousness, making central lines secondary, as they address fluid or medication needs, not TBI-specific issues.

Choice C reason: NGT insertion is anticipated, as traumatic brain injury often impairs swallowing or consciousness, increasing aspiration risk. The tube decompresses the stomach or delivers nutrition, preventing complications like pneumonia, making it a priority procedure to support TBI management and patient stability.

Choice D reason: Pacemaker placement addresses cardiac arrhythmias, unrelated to traumatic brain injury. NGT insertion manages gastric or nutritional needs in TBI, where neurological deficits are primary, making pacemakers irrelevant, as TBI does not typically involve acute cardiac conduction issues.

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Correct Answer is B

Explanation

Choice A reason: Palpable cervical lymph nodes suggest infection or malignancy, not stroke risk. Stroke is linked to vascular issues like carotid stenosis, detected by bruit. Lymph nodes are unrelated to cerebrovascular pathology, making this finding irrelevant for identifying stroke risk in the client.

Choice B reason: Carotid bruit indicates turbulent flow from stenosis, a major stroke risk due to potential embolism or reduced cerebral perfusion. This vascular finding directly correlates with ischemic stroke, making it the most critical assessment to report for stroke prevention and evaluation.

Choice C reason: Nuchal rigidity suggests meningitis or subarachnoid hemorrhage, not ischemic stroke risk. Carotid bruit is a specific precursor to embolic stroke, and nuchal rigidity addresses different neurological conditions, making this finding less relevant for stroke risk assessment.

Choice D reason: Jugular vein distention indicates heart failure or venous pressure, not arterial stroke risk. Carotid bruit directly relates to cerebrovascular disease, a stroke precursor, making jugular distention irrelevant, as it reflects cardiovascular, not cerebrovascular, pathology in stroke risk evaluation.

A. Avoid the consumption of wine, beer, and coffee B. Take prescribed pain medication after exercising joints C. Replace dietary table salt with salt substitutes D. Encourage active range of motion to limit stiffness

Correct Answer is A

Explanation

Choice A reason: Avoiding wine, beer, and coffee is critical, as alcohol and purine-rich beverages increase uric acid, triggering gout attacks. These exacerbate hyperuricemia, worsening toe inflammation. This dietary restriction prevents recurrent flares, making it a key instruction for managing gouty arthritis effectively.

Choice B reason: Taking pain medication after exercising joints is incorrect, as exercise during a gout attack worsens inflammation. Pain relief should precede activity, and rest is advised during flares, making this instruction harmful, as it risks exacerbating the client’s toe pain.

Choice C reason: Replacing table salt with substitutes is irrelevant to gout, as salt does not affect uric acid metabolism. Gout management focuses on reducing purines and alcohol, and salt substitutes may contain potassium, unrelated to inflammation, making this instruction ineffective.

Choice D reason: Encouraging active range of motion during a gout attack increases joint stress, worsening inflammation. Rest is recommended during acute flares, and mobility is introduced later, making this instruction counterproductive, as it risks prolonging pain and delaying recovery.

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A client is admitted to the intensive care unit (ICU) with a traumatic brain injury. Which invasive procedure should the nurse anticipate preparing the client to undergo?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse reports that a client is at risk for a stroke based on which assessment finding?

Correct Answer is B

Explanation

A client who is experiencing a first gouty arthritis attack reports excruciating pain in the right great toe. The nurse inspects the inflamed joint and administers ibuprofen 800 mg PO as prescribed. Which instruction should the nurse include in the discharge teaching?

Correct Answer is A

Explanation

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