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 A

Explanation

A. Hypokalemia: U waves are often seen on an electrocardiogram in clients with hypokalemia. They represent delayed repolarization of the Purkinje fibers due to low potassium levels.

B. Hypercalcemia: Hypercalcemia affects the QT interval, typically shortening it, but it does not cause U waves.

C. Hyponatremia: Electrocardiographic changes are not commonly associated with hyponatremia.

D. Hyperkalemia: Hyperkalemia causes peaked T waves, prolonged PR intervals, and wide QRS complexes, not U waves.

A. Occurs during stress B. Occurs without any EKG changes C. Occurs with reversible EKG changes D. Occurs at rest

Correct Answer is D

Explanation

A. Occurs during stress: This describes stable angina, which is precipitated by predictable stress or exertion.

B. Occurs without any EKG changes: Unstable angina often presents with reversible ischemic EKG changes, such as ST depression or T wave inversion.

C. Occurs with reversible EKG changes: While this is true for unstable angina, it is not the primary differentiator compared to other types of angina.

D. Occurs at rest: Correct. Unstable angina is characterized by chest pain that occurs at rest or with minimal exertion, differentiating it from stable angina.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

The nurse is assessing a client with unstable angina. Which finding would the nurse expect the client to report that differentiates this from other types of anginas?

Correct Answer is D

Explanation

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 teaching a class to a group of staff nurses about traumatic brain injury which condition would the nurse identify as having the highest risk of a fatal outcome within the first 24 hours post-injury?

The nurse is assessing a 28-year-old client who sustained a spinal injury after diving into a shallow pool. Which finding would indicate that the client has a C-1 to C-2 injury?

The patient is asymptomatic but is diagnosed with second-degree heart block Mobitz 1. The patient is on digoxin at home. Which of the following interventions will the nurse anticipate?

A nurse is preparing to administer warfarin to a client with a mechanical valve replacement. The client's INR is 2.7. Which action should the nurse implement?

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?

The nurse is caring for a client who sustained a crushed injury to the lower extremity and has developed compartment syndrome. What intervention should the nurse plan for next?

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?