A nurse is caring for a client who has a traumatic brain injury. The client says to the nurse, "I don't remember what happened to me." How should the nurse respond?

"You have a brain injury that affects your memory."

"Don't worry, your memory will come back soon."

"What do you think happened to you?"

"Tell me more about how you feel right now."

Answer and Explanation

The Correct Answer is D

Choice A reason:

This is an incorrect answer. The nurse should not give information that might overwhelm or distress the client without assessing their readiness to learn.

Choice B reason:

This is an incorrect answer. The nurse should not give false reassurance or minimize the client's condition.

Choice C reason:

This is an incorrect answer. The nurse should not ask questions that might confuse or frustrate the client who has memory impairment.

Choice D reason:

This is a correct answer. The nurse should use therapeutic communication techniques such as exploring feelings, reflecting, and active listening to provide emotional support and establish rapport with the client.

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Correct Answer is A

Explanation

Choice A reason:

This is a correct answer. Elevating the head of the bed to 30 degrees helps to reduce ICP by facilitating venous drainage from the brain and decreasing cerebral edema.

Choice B reason:

This is an incorrect answer. Administering morphine sulfate for pain relief can increase ICP by causing vasodilation, respiratory depression, and increased carbon dioxide levels in the blood.

Choice C reason:

This is an incorrect answer. Encouraging coughing and deep breathing exercises can increase ICP by increasing intrathoracic pressure, which impedes venous drainage from the brain.

Choice D reason:

This is an incorrect answer. Performing passive range of motion exercises can increase ICP by stimulating the sympathetic nervous system, which increases blood pressure and cerebral blood flow.

A. The central nervous system processes sensory information and generates motor commands. B. The peripheral nervous system consists of the brain and spinal cord. C. The autonomic nervous system regulates involuntary functions of smooth muscles, cardiac muscles, and glands. D. The sympathetic nervous system prepares the body for stress or emergency situations.

Correct Answer is B

Explanation

Choice A reason:

This is a correct statement. The central nervous system (CNS) is responsible for processing sensory information, generating motor commands, and regulating cognitive and emotional functions.

Choice B reason:

This is an incorrect statement. The peripheral nervous system (PNS) consists of the cranial nerves, spinal nerves, and ganglia that connect the CNS to the rest of the body.

Choice C reason:

This is a correct statement. The autonomic nervous system (ANS) regulates involuntary functions of smooth muscles, cardiac muscles, and glands. It has two branches: the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS).

Choice D reason:

This is a correct statement. The sympathetic nervous system (SNS) prepares the body for stress or emergency situations by increasing heart rate, blood pressure, respiratory rate, and blood glucose levels. It also dilates the pupils, bronchi, and blood vessels to skeletal muscles.

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A nurse is caring for a client who has a traumatic brain injury. The client says to the nurse, "I don't remember what happened to me." How should the nurse respond?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has increased intracranial pressure (ICP) due to a brain tumor. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is teaching a client about the functions of the nervous system. Which of the following statements by the client indicates a need for further teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who has a traumatic brain injury. The client says to the nurse, "I don't remember what happened to me." How should the nurse respond?

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