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 B
Explanation
Choice A rationale
While a stiff neck can be a symptom of a cerebral aneurysm, it is not a definitive sign. A stiff neck is more commonly associated with conditions like meningitis.
Choice B rationale
Most cerebral aneurysms do not cause symptoms until they rupture or become very large. Therefore, a person with a cerebral aneurysm typically will have no symptoms.
Choice C rationale
Seizures can occur if a cerebral aneurysm ruptures and causes bleeding in the brain. However, seizures are not a common symptom of unruptured cerebral aneurysms.
Choice D rationale
Nausea and vomiting can occur if a cerebral aneurysm ruptures and causes a sudden increase in intracranial pressure. However, these are not typical symptoms of an unruptured cerebral aneurysm.
Correct Answer is ["B","D"]
Explanation
Choice A rationale
Oxycodone is an opioid medication, not a nonopioid analgesic. It is used for the relief of moderate to severe pain but has a high potential for addiction and dependence.
Choice B rationale
Ibuprofen is a nonopioid analgesic. It belongs to a class of drugs known as nonsteroidal anti- inflammatory drugs (NSAIDs) and is commonly used to relieve pain, reduce inflammation, and lower fever.
Choice C rationale
Fentanyl is a potent opioid pain medication. It is not a nonopioid analgesic. It is used for managing severe pain, often in people who have built up a resistance to other opioids.
Choice D rationale
Acetaminophen is a nonopioid analgesic. It is used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, and reactions to vaccinations, and to reduce fever.
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