A nurse is caring for a client who has a traumatic brain injury and is being mechanically ventilated. Which of the following can cause unfavorable outcomes for this client?
Hyperoxia
Platelet count 250,000/mm^3
Hemoglobin 16 g/dL
Glasgow Coma Scale 16
The Correct Answer is A
Choice A rationale
Hyperoxia, or high oxygen levels, can cause unfavorable outcomes for a client who has a traumatic brain injury and is being mechanically ventilated. Too much oxygen can lead to oxygen toxicity and cause damage to the lungs and other organs, including the brain.
Choice B rationale
A platelet count of 250,000/mm^3 is within the normal range and would not typically cause unfavorable outcomes for a client who has a traumatic brain injury and is being mechanically ventilated.
Choice C rationale
A hemoglobin level of 16 g/dL is within the normal range and would not typically cause unfavorable outcomes for a client who has a traumatic brain injury and is being mechanically ventilated.
Choice D rationale
A Glasgow Coma Scale score of 16 is not possible as the maximum score is 15. A higher score indicates a less severe injury, so it would not typically cause unfavorable outcomes for a client who has a traumatic brain injury and is being mechanically ventilated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
This statement is incorrect. Nerves do not “go to sleep.”. Peripheral neuropathy in diabetes is caused by damage to the nerves as a result of high blood sugar levels over time.
Choice B rationale
This statement is incorrect. While nerve damage can occur due to various reasons, in the context of diabetes, it is primarily due to prolonged high blood sugar levels.
Choice C rationale
This statement is incorrect. Age and blood flow to the feet are not the primary causes of peripheral neuropathy in diabetes. The primary cause is prolonged high blood sugar levels.
Choice D rationale
This statement is correct. Prolonged high blood sugar levels in diabetes can cause damage to the peripheral nerves, leading to peripheral neuropathy.
Correct Answer is B
Explanation
Choice A rationale
While emotional disorders and acute pain can occur after a traumatic brain injury (TBI), they are not considered secondary conditions. These are more immediate and direct results of the injury.
Choice B rationale
Loss of sensation and cognition difficulties are common secondary conditions that can develop after a TBI. These can be due to damage to specific areas of the brain during the injury.
Choice C rationale
Body dysmorphia and neurofibrillary tangles are not typically associated with TBI. Body dysmorphia is a psychological disorder, and neurofibrillary tangles are associated with neurodegenerative diseases like Alzheimer’s.
Choice D rationale
Decreased appetite and a lack of sleep can occur after a TBI, but they are more likely to be symptoms rather than secondary conditions. Secondary conditions are typically more long- term and are a result of changes in the brain after the injury.
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