A nurse is planning care for a client who has a mild traumatic brain injury (TBI). Which of the following should the nurse include in the plan of care?

Response to noxious stimuli

Obstructive sleep apnea

Trousseau's sign

Cranial nerve assessment

Answer and Explanation

The Correct Answer is D

A. Response to noxious stimuli: While assessing the response to noxious stimuli can be an important part of neurological assessment, it is not specific to mild traumatic brain injury (TBI). The primary focus should be on cranial nerve assessment to evaluate brain function and detect any early signs of deterioration.
B. Obstructive sleep apnea: Obstructive sleep apnea is not a typical concern for a client with mild TBI. The focus should be on the immediate effects of the injury, such as cranial nerve function, rather than conditions unrelated to the head injury.
C. Trousseau's sign: Trousseau's sign is a test used to assess for latent tetany (muscle spasms), typically in cases of hypocalcemia. It is not relevant for a client with mild TBI unless there are other symptoms indicating electrolyte imbalances, which are not the primary concern in this case.
D. Cranial nerve assessment: Cranial nerve assessment is a key part of evaluating the neurological status of a client with mild TBI. It helps identify any deficits or changes in brain function that may indicate deterioration or more severe injury. This should be part of the plan of care for a mild TBI client.

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Correct Answer is B

Explanation

A. Cyanosis: Cyanosis can occur as ARDS progresses due to severe hypoxemia, but it is not usually the earliest or most common presenting symptom. It tends to appear later when oxygen saturation is critically low.
B. Dyspnea: Dyspnea, or shortness of breath, is the most common and often the earliest manifestation of ARDS. It results from impaired gas exchange caused by fluid accumulation in the alveoli and inflammation of the lung tissue.
C. Diaphoresis: Diaphoresis may be present as a response to respiratory distress or sympathetic nervous system activation but is nonspecific and not unique to ARDS. It is not considered the primary presenting sign.
D. Somnolence: Somnolence typically develops in later stages of ARDS as oxygen levels drop significantly and carbon dioxide retention increases. It reflects worsening respiratory failure rather than an early sign.

A. Coughing B. Motor vehicle accidents C. Falls D. Assault

Correct Answer is B

Explanation

A. Coughing: While coughing can be a symptom of respiratory distress or lung injury, it is not typically a direct cause of flail chest. Flail chest is characterized by multiple rib fractures leading to a segment of the chest wall moving independently, which can result from blunt trauma like a motor vehicle accident.
B. Motor vehicle accidents: Flail chest commonly results from significant trauma, such as that from a motor vehicle accident. The blunt force of the impact during an accident can cause multiple rib fractures, which can result in the characteristic paradoxical chest movement seen in flail chest.
C. Falls: Although falls can result in rib fractures, they are less likely to cause the severe trauma and multiple rib fractures required to result in flail chest. While serious falls could contribute to a flail chest in certain scenarios, motor vehicle accidents are more common for this type of injury.
D. Assault: While an assault can cause chest injuries, including rib fractures, it is less commonly associated with flail chest compared to the more significant force from motor vehicle accidents. The mechanism of injury in assaults may not involve the level of blunt trauma that leads to multiple rib fractures and flail chest.

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A nurse is planning care for a client who has a mild traumatic brain injury (TBI). Which of the following should the nurse include in the plan of care?

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