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","D","E"]

Explanation

A. "Are you having any feelings of depression?" Migraines can have a significant psychosocial impact, and many clients with chronic migraines experience mood disorders such as depression. Asking about depressive symptoms helps assess emotional well-being and determine if referral for mental health support is necessary.
B. "Are you experiencing any sensitivity to light?" Photophobia is a common physical symptom of migraines, not a psychosocial effect. Although it's important in clinical assessment, this question does not assess the psychosocial impact, which is the focus of this evaluation.
C. "Are you feeling any increase in your sexual drive?" Changes in libido are not typically associated with migraines or their psychosocial consequences. This question is not relevant to understanding the emotional or social impact of migraines on a client's daily life.
D. "Are you experiencing any episodes of 'panic-type feelings?" Migraines may contribute to anxiety and panic-like symptoms, especially in clients who feel a loss of control over their condition. Evaluating for panic episodes is essential in assessing the broader psychosocial burden of chronic migraines.
E. "Are you experiencing more fatigue as compared to before you had migraines?"
Fatigue is a frequent and often overlooked psychosocial consequence of chronic migraines. It can affect quality of life, work performance, and social interactions, making this a key aspect of psychosocial assessment.

A. The SA node sends an electrical signal greater than 100/min. B. The heart's electrical signals are rapid, chaotic, and irregular. C. An early electrical signal occurs before the expected sinoatrial (SA) node signal. D. The heart's electrical transmission through the atrioventricular (AV) node is unusually slow.

Correct Answer is B

Explanation

A. The SA node sends an electrical signal greater than 100/min: A fast SA node firing rate may indicate sinus tachycardia, not atrial fibrillation. In atrial fibrillation, the SA node is not the primary pacemaker because disorganized signals originate from multiple ectopic foci in the atria, leading to ineffective atrial contractions.
B. The heart's electrical signals are rapid, chaotic, and irregular: In atrial fibrillation, the atria experience disorganized and chaotic electrical impulses, causing an irregular and often rapid heart rhythm. This results in decreased cardiac output, leading to symptoms like dizziness and palpitations due to poor perfusion.
C. An early electrical signal occurs before the expected sinoatrial (SA) node signal: This describes a premature atrial contraction (PAC), not atrial fibrillation. PACs are isolated early beats and do not typically result in sustained irregular rhythms or significant hemodynamic symptoms like those seen in atrial fibrillation.
D. The heart's electrical transmission through the atrioventricular (AV) node is unusually slow:
Delayed conduction through the AV node is associated with AV blocks, not atrial fibrillation. While AV conduction may be variable in atrial fibrillation, the root problem lies in the atria, not in slowed AV nodal transmission.

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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 caring for a client who reports continuing problems related to migraines. The nurse is assessing the psychosocial impact of migraines on the client. Which of the following questions should the nurse include in the assessment? (Select All that Apply.)

Correct Answer is ["A","D","E"]

Explanation

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Correct Answer is B

Explanation

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