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 ["A","D","F"]
Explanation
Choice A rationale
Patients with poorly controlled diabetes, such as those experiencing diabetic ketoacidosis (DKA), are at an increased risk of developing peripheral neuropathy. High blood sugar levels can damage peripheral nerves over time.
Choice B rationale
Sleep apnea is not typically associated with an increased risk of developing peripheral neuropathy.
Choice C rationale
While hypertension can lead to a variety of health complications, it is not typically associated with an increased risk of developing peripheral neuropathy.
Choice D rationale
Systemic Lupus Erythematosus (SLE) is an autoimmune disease that can affect the nervous system, including the peripheral nerves, leading to peripheral neuropathy.
Choice E rationale
Untreated tuberculosis is not typically associated with an increased risk of developing peripheral neuropathy.
Choice F rationale
Chronic alcohol use can lead to nutritional deficiencies, particularly of the B vitamins, which are essential for nerve health. This can result in peripheral neuropathy.
Correct Answer is C
Explanation
Choice A rationale
Smoking is a risk factor for many health conditions, including headaches. However, it is not a common precipitating factor in both tension-type and cluster headaches.
Choice B rationale
Depression can be associated with both tension-type and cluster headaches, but it is not a common precipitating factor for these types of headaches.
Choice C rationale
Stress is a common precipitating factor for both tension-type and cluster headaches. Both types of headaches can be triggered by psychological factors like stress.
Choice D rationale
Poor posture can contribute to tension-type headaches by causing muscle tension in the neck and shoulders. However, it is not a common precipitating factor for cluster headaches.
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