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?

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.

A. "Your heart condition is caused when the ventricular tissue becomes fibrous and fatty": This description aligns more with restrictive cardiomyopathy. Dilated cardiomyopathy (DCM) involves the enlargement and weakening of the ventricles rather than fibrous or fatty tissue replacement.
B. "Your heart condition is caused by excessive stretching of the ventricles": Dilated cardiomyopathy is characterized by the excessive stretching of the ventricles, leading to poor contraction and reduced pumping efficiency. This is the most accurate explanation of the condition.
C. "Your heart condition is caused by thickening of the ventricular walls and septum": This description refers to hypertrophic cardiomyopathy, not dilated cardiomyopathy. Hypertrophic cardiomyopathy is characterized by thickened heart walls, not dilation.
D. "Your heart condition is caused from stiffening of the walls of the ventricles": This description refers to restrictive cardiomyopathy, where the heart walls become stiff and less able to expand and contract properly, not dilated cardiomyopathy.