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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Regulation of the amount of carbon dioxide exhaled can affect cerebral blood flow, but it does not directly maintain cerebral perfusion pressure constant.
Choice B rationale
Catecholamines circulating throughout the body can affect blood pressure and heart rate, but they do not directly maintain cerebral perfusion pressure constant.
Choice C rationale
How much blood is pumped from the heart, also known as cardiac output, can affect cerebral perfusion pressure. However, it does not directly maintain cerebral perfusion pressure constant.
Choice D rationale
Regulation of constriction and dilation of blood vessels in the brain, also known as cerebral autoregulation, is a key mechanism that maintains cerebral perfusion pressure constant. When pressure autoregulation is impaired, cerebral blood flow becomes dependent on cerebral perfusion pressure.
Correct Answer is B
Explanation
Choice A rationale
Cancer pain is usually associated with the growth of a tumor or the side effects of cancer treatment. Phantom limb pain is not related to cancer.
Choice B rationale
Phantom limb pain is considered a type of neuropathic pain. This is because it is associated with nerve damage or malfunctioning nerves in the area where the limb was amputated.
Choice C rationale
Chronic pain is a broad term that refers to any pain that lasts for more than 12 weeks. While phantom limb pain can become chronic, this term does not specifically describe the type of pain experienced in phantom limb syndrome.
Choice D rationale
Acute pain is a type of pain that comes on suddenly and has a specific cause, usually related to tissue damage. Phantom limb pain is not considered acute pain because it is not related to new tissue damage.
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