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

Assess palmar reflex.

Assess for cough reflex.

Assess the ability to follow simple commands.

Assess for Cushing's Triad.

Assess for abnormal posturing.

Answer and Explanation

Correct Answer : A,B,C,D,E

A. Assess palmar reflex. Assessing the palmar reflex helps evaluate the integrity of the nervous system, particularly in response to tactile stimuli. In clients with severe TBI, abnormal reflexes may indicate neurological impairment and guide further assessment and intervention.

B. Assess for cough reflex. Assessing the cough reflex is important for evaluating airway protection and the risk of aspiration, especially in clients with reduced consciousness level due to TBI.

C. Assess the ability to follow simple commands. Assessing the client's ability to follow simple commands provides valuable information about their level of consciousness and cognitive function. It helps determine the extent of neurological impairment and guides the plan of care, including interventions for communication and cognitive deficits.

D. Assess for Cushing's Triad. Cushing's Triad, characterized by hypertension, bradycardia, and irregular respirations, may occur as a late sign of increased intracranial pressure (ICP) in clients with severe TBI. Monitoring for Cushing's Triad is crucial for early recognition of elevated ICP and prompt intervention to prevent further neurological damage.

E. Assess for abnormal posturing. Assessing for abnormal posturing, such as decerebrate or decorticate posturing, helps evaluate neurological function and localize brain injury in clients with TBI. Abnormal posturing indicates severe brain damage and may guide decisions regarding treatment and prognostication.

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Correct Answer is D

Explanation

A. Stress can contribute to the development of atrial flutter, but it is not the highest risk factor compared to other options.

B. While electrolyte imbalances resulting from vomiting and diarrhea can predispose someone to arrhythmias, they are not as significant a risk factor for atrial flutter as other conditions.

C. A family history of atrial flutter may increase the likelihood of developing the condition, but it is not as significant a risk factor compared to other options.

D. A history of myocardial infarction and stent placement indicates underlying heart disease, which is a significant risk factor for developing atrial flutter. Cardiac events like myocardial infarction can lead to structural changes in the heart, such as scarring or remodeling, which can predispose individuals to atrial flutter. Therefore, this client is at the highest risk for developing atrial flutter among the options provided.

A. "Medications for Alzheimer's disease will help to increase my energy levels." B. "Medications for Alzheimer's disease will help slow the progression of my disease." C. "Medications for Alzheimer's disease will help me remember what I forgot." D. "Medications for Alzheimer's disease will cure the disease."

Correct Answer is B

Explanation

A. "Medications for Alzheimer's disease will help to increase my energy levels": This statement is not accurate. Medications for Alzheimer's disease, such as cholinesterase inhibitors (e.g., donepezil, rivastigmine) and memantine, are not intended to increase energy levels. Their primary goal is to improve cognitive function and help manage symptoms associated with Alzheimer's disease, but they do not directly affect energy levels.

B. "Medications for Alzheimer's disease will help slow the progression of my disease": This statement is correct. Medications used to treat Alzheimer's disease, such as cholinesterase inhibitors and memantine, are aimed at slowing the progression of cognitive decline and managing symptoms associated with the disease. While these medications cannot cure Alzheimer's disease, they can help improve cognitive function and quality of life for some individuals.

C. "Medications for Alzheimer's disease will help me remember what I forgot": This statement oversimplifies the effects of Alzheimer's medications. While these medications may help improve memory and cognition to some extent, they are not capable of restoring lost memories or reversing the effects of significant memory impairment caused by Alzheimer's disease.

D. "Medications for Alzheimer's disease will cure the disease": This statement is incorrect. Currently, there is no cure for Alzheimer's disease. Medications used to treat Alzheimer's, such as cholinesterase inhibitors and memantine, can help manage symptoms and slow disease progression, but they do not cure the underlying condition.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a group of clients about risk factors for developing atrial flutter. Which of the following clients should the nurse understand is at highest risk for developing atrial flutter?

Correct Answer is D

Explanation

A nurse is teaching a client who is newly diagnosed with Alzheimer's disease and their family about newly prescribed medications for Alzheimer's disease. Which statement by the client indicates the teaching was effective?

Correct Answer is B

Explanation

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