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A nurse is caring for a client in the intensive care unit who was admitted with severe head trauma and cerebral edema. The client opens their eyes spontaneously, is oriented, and obeys commands. Which of the following findings indicate the client is experiencing a decline in their condition?
(Select All that Apply.)

Client responds to name

Eyes open to painful stimuli

Client states day of the week

Client is confused

Client mumbles inappropriate words

Eyes do not open to name

Answer and Explanation

Correct Answer : B,D,E,F

Choice A Reason:

Client responds to name is incorrect. Responding to one's name is a positive sign indicating consciousness and orientation. It suggests that the client's level of consciousness is relatively intact.

Choice B Reason:

Eyes open to painful stimuli is correct. Opening the eyes in response to painful stimuli is a concerning sign, indicating a decrease in consciousness and potentially worsening neurological status. It suggests that the client's level of arousal is diminishing and may indicate a decline in condition.

Choice C Reason:

Client states day of the week is correct. Oriented behavior, such as knowing the day of the week, is a positive sign indicating intact cognition and orientation. It suggests that the client's mental status is relatively preserved.

Choice D Reason:

Client is confused is correct. Confusion is a concerning sign, indicating altered mental status and potentially worsening neurological function. It suggests that the client's cognition is impaired, which may be indicative of a decline in condition.

Choice E Reason:

Client mumbles inappropriate words is correct. Mumbling inappropriate words suggests disorientation and altered mental status, which are concerning signs indicating a decline in neurological function.

Choice F Reason:

Eyes do not open to name is incorrect. Failure to open the eyes in response to verbal stimuli, such as one's name, is a concerning sign indicating a decrease in consciousness and potentially worsening neurological status. It suggests that the client's level of arousal is diminished and may indicate a decline in condition.

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Correct Answer is A

Explanation

Choice A Reason:

Smoking tobacco is the primary and most significant risk factor for emphysema. Tobacco smoke contains harmful chemicals and toxins that directly damage the lungs. Chronic exposure to cigarette smoke leads to inflammation and destruction of lung tissue, particularly the alveoli, contributing to the development of emphysema.

Choice B Reason:

Between 20 to 30 years of age. While smoking at any age is harmful to lung health, the risk of developing emphysema increases with prolonged exposure to tobacco smoke over many years. Emphysema is typically a disease of middle to older age, with symptoms often appearing after years of smoking.

Choice C Reason:

Asthma is a chronic inflammatory condition of the airways characterized by reversible airflow obstruction and airway hyperresponsiveness. While asthma and emphysema are both respiratory diseases, they have distinct pathophysiological mechanisms and risk factors. Asthma is not a direct cause of emphysema, although some individuals with poorly controlled asthma may develop chronic obstructive pulmonary disease (COPD), which includes emphysema as one of its components.

Choice D Reason:

Pollution is not correct. Environmental pollution, including air pollution from industrial emissions, vehicle exhaust, and particulate matter, can contribute to respiratory problems and exacerbate pre-existing lung conditions. While exposure to pollution can worsen respiratory symptoms and lung function, it is not the primary cause of emphysema. However, long-term exposure to certain pollutants may increase the risk of developing respiratory diseases, including COPD, which encompasses emphysema.

A. Take small bites of food. B. Liquids should be thickened. C. Eat sitting slightly forward. D. Chew food thoroughly before swallowing. E. Avoid having conversations while eating. F. Avoid fiber in the diet.

Correct Answer is ["A","C","D"]

Explanation

Choice A Reason:

Take small bites of food is correct. Taking small bites of food can help prevent choking and aspiration, particularly during mealtime. It is a recommended practice for individuals with epilepsy to reduce the risk of aspiration if a seizure were to occur during eating.

Choice B Reason:

Liquids should be thickened is incorrect. Thickened liquids are typically recommended for individuals with swallowing difficulties (dysphagia) to help prevent aspiration. However, thickened liquids may not be necessary for all individuals with epilepsy unless specifically indicated based on their swallowing function assessment.

Choice C Reason:

Eat sitting slightly forward correct.: Eating while sitting slightly forward can help prevent aspiration in case of a seizure during meals. This position allows gravity to assist in preventing food or liquid from entering the airway.

Choice D Reason:

Chew food thoroughly before swallowing is correct. Thoroughly chewing food before swallowing is important for proper digestion and to reduce the risk of choking or aspiration, especially for individuals with epilepsy who may be at increased risk of aspiration during a seizure.

Choice E Reason:

Avoid having conversations while eating is incorrect. Avoiding conversations while eating is not directly related to epilepsy management. However, focusing on eating and taking appropriate precautions, such as sitting upright and chewing food thoroughly, can help reduce the risk of aspiration during meals.

Choice F Reason:

Avoid fiber in the diet is incorrect.: There is no specific recommendation to avoid fiber in the diet for individuals with epilepsy. In fact, a balanced diet that includes fiber-rich foods can promote overall health and well-being, which is important for individuals with epilepsy as well.

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Naxlex Comprehensive Predictor Exams

Which of the following is the most common risk factor for emphysema?

Correct Answer is A

Explanation

A nurse is providing discharge instructions to a client who has epilepsy. Which of the following instructions should be included in the nurse's teaching? (Select All that Apply.)

Correct Answer is ["A","C","D"]

Explanation

Which of the following information should the nurse include when educating a client who has pulmonary edema as a result of a pre-existing cardiac condition? (Select All that Apply.)

A nurse is caring for a client who has multiple sclerosis. Which of the following factors should the nurse anticipate have been identified as contributing to the development of multiple sclerosis? (Select All that Apply.)

A client who has a history of migraines reports to a clinic with a throbbing headache. Which of the following questions should the nurse include in the assessment? (Select All that Apply.)

A nurse is caring for a client who reports continuing problems related to migraines. The nurse is assessing the psychosocial impact of migraines on the client. Which of the following questions should the nurse include in the assessment? (Select All that Apply.)

A nurse is caring for a group of clients in a medical unit. Which of the following clients is at the highest risk for developing osmotic cerebral edema?

A nurse is assessing a client who has tension pneumothorax. Which of the following findings should the nurse expect following tracheal deviation?

A nurse is planning care for a client who has neurogenic shock following a spinal cord injury. Which of the following provider prescriptions should the nurse anticipate? (Select all that apply.) (Select All that Apply.)

A nurse is providing care for a client who is at risk of cerebral aneurysm rupture. Which of the following interventions should the nurse include in the care plan?