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 A

Explanation

A. 3% sodium chloride: A serum sodium level of 115 mEq/L is dangerously low, indicating severe hyponatremia. The nurse should anticipate that a hypertonic saline solution such as 3% sodium chloride will be prescribed to rapidly increase the sodium concentration in the blood and treat the underlying SIADH.
B. Dextrose 5% in 0.99% sodium chloride: This is an isotonic solution and would not be suitable for treating severe hyponatremia in SIADH, as it would not significantly increase sodium levels. Hypertonic saline solutions are more appropriate for severe cases of hyponatremia.
C. Dextrose 5% in 0.45% sodium chloride: This solution is hypotonic and could worsen hyponatremia by diluting the sodium further. It should not be used to treat SIADH with severely low sodium levels.
D. 0.9% sodium chloride: Normal saline (0.9% sodium chloride) is isotonic and would not correct the low sodium levels as effectively as hypertonic saline. While it is used in less severe cases, 3% sodium chloride is necessary in cases of severe hyponatremia.

A. Guillain-Barré syndrome B. Emphysema C. Congestive heart failure D. Flail chest

Correct Answer is B

Explanation

A. Guillain-Barré syndrome: Guillain-Barré syndrome causes respiratory failure due to neuromuscular weakness, leading to hypoventilation. It does not typically cause a ventilation-perfusion (V/Q) mismatch because the lungs themselves remain structurally intact. The issue lies in impaired respiratory muscle function, not mismatched gas exchange.
B. Emphysema: Emphysema is a chronic obstructive pulmonary disease (COPD) characterized by alveolar wall destruction, which leads to impaired gas exchange and areas of the lung being ventilated but poorly perfused, or vice versa. This results in a V/Q mismatch, making it a common cause of respiratory failure due to this mechanism.
C. Congestive heart failure: While CHF can cause pulmonary edema and impair oxygen exchange, it typically leads to hypoxemia through fluid buildup in the alveoli rather than classic V/Q mismatch. The primary problem is poor oxygen diffusion due to fluid, not mismatched ventilation and perfusion.
D. Flail chest: Flail chest results in respiratory failure primarily due to paradoxical chest wall movement and impaired ventilation mechanics. Although oxygenation may be compromised, it is not primarily a V/Q mismatch but rather ineffective ventilation from the instability of the chest wall.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to provide care for a client in the emergency department who has syndrome of inappropriate antidiuretic hormone (SIADH). The client has a serum sodium of 115 mEq/L (136-145 mEq/L). Which of the following IV solutions should the nurse anticipate will be prescribed?

Correct Answer is A

Explanation

A nurse is caring for a client who has respiratory failure due to ventilation-perfusion (V/Q) mismatch. The nurse should recognize that the client most likely has which of the following conditions?

Correct Answer is B

Explanation

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