A nurse is caring for an adolescent client who was in a vehicle collision and has suffered a major head injury. The client's parents are considering organ donation and ask the nurse how the health care providers determine brain death. Which response by the nurse accurately describes brain death determination?

"Brain death has occurred if there is no spontaneous breathing or brainstem reflexes.

“If respiratory efforts cease and no apical pulse is audible, brain death is present."

"Brain death has occurred if a person has flaccid muscles and does not awaken.

“CPR does not restore a heartbeat; the brain cannot function."

Answer and Explanation

The Correct Answer is A

A. “Brain death has occurred if there is no spontaneous breathing or brainstem reflexes.” Brain death is defined as the irreversible cessation of all functions of the entire brain, including the brainstem. The absence of spontaneous breathing and brainstem reflexes (such as pupillary response, gag reflex, and eye movements) are critical criteria used to confirm brain death.

B. “If respiratory efforts cease and no apical pulse is audible, brain death is present.” While the cessation of respiratory efforts is a key component of brain death, the presence or absence of an apical pulse alone is not sufficient for determining brain death. Brain death is determined based on the complete absence of brain function, including brainstem reflexes.

C. “Brain death has occurred if a person has flaccid muscles and does not awaken.” Muscle flaccidity and lack of consciousness may be signs of severe brain injury, but they do not necessarily confirm brain death. Brain death is diagnosed based on the absence of brainstem reflexes and spontaneous breathing.

D. “CPR does not restore a heartbeat, the brain cannot function.” While it is true that CPR may not restore circulation in brain-dead patients, this statement is incomplete and not a precise definition of brain death. Brain death is determined by the irreversible cessation of all brain activity, not just by the failure of CPR to restore circulation.

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Correct Answer is D

Explanation

A. “There is some swelling in your right leg that is making you feel this way.” Swelling would typically cause discomfort or pressure, but it would not be responsible for the sensation of pain in the amputated limb.

B. "Your brain is responding to being inactive from the surgery." This answer does not address the real cause of the pain, which is related to the brain's continued perception of the missing limb.

C. "Don't worry about your right foot. The pain will go away within a few days." Phantom limb pain is a common phenomenon after amputation and may persist long-term. Dismissing it is not appropriate.

D. "Your brain is still receiving impulses about your right foot." This is an accurate explanation for phantom limb pain. After amputation, the brain may still interpret sensations from the absent limb, causing pain or discomfort in the "missing" foot.

A. Sinus rhythm with first-degree heart block B. ST-segment elevation myocardial infarction (STEMI) C. Atrial fibrillation D. Ventricular tachycardia

Correct Answer is B

Explanation

A. Sinus rhythm with first-degree heart block: This rhythm is characterized by a regular sinus rhythm with a prolonged PR interval (greater than 0.20 seconds), indicating a first-degree heart block.

B. ST-segment elevation myocardial infarction (STEMI): STEMI is indicated by significant ST-segment elevation in specific leads, showing acute myocardial infarction.

C. Atrial fibrillation: Atrial fibrillation shows an irregularly irregular rhythm without distinct P waves.

D. Ventricular tachycardia: Ventricular tachycardia is a rapid heart rhythm originating from the ventricles, with wide QRS complexes and no preceding P waves.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is postoperative following a right below-the-knee amputation. The client asks the nurse, " I keep having pain in my right foot. Why is that?" Which response would be appropriate for the nurse to make?

Correct Answer is D

Explanation

The nurse is caring for a client on a telemetry unit. The client's cardiac monitor exhibits the rhythm below. How should the nurse document this rhythm?

Correct Answer is B

Explanation

The nurse is providing discharge instructions to a 76-year-old male client with chronic atrial fibrillation who has a CHA2DS2-VASC score of 2. Which medication would the nurse identify as most likely to be prescribed for the client?

A client has undergone a right femoral cardiac catheterization. What nursing action is the priority following the procedure?

The nurse is caring for a client who suffered a hemorrhagic stroke. In order to prevent increased intracranial pressure, the client should be placed in which position for the first 72 hours after the onset of a stroke?

The nurse is assessing the cardiac rhythm of a client who is admitted with coronary artery disease. The nurse notes that the PR interval is 0.24 and the QRS interval is 0.10. Which interpretation would be appropriate for the nurse to make

A nurse is providing discharge education to a client who is going home with a cast on his leg. What education should the nurse emphasize in the teaching session?

The nurse is assessing a client who is near death. Which of the following findings would indicate to the nurse that the client is in the actively dying phase?

The nurse is teaching a group of staff nurses about cardiac rhythms. The nurse would indicate that a U wave may indicate which of the following?