A nurse is planning care for a client who has a traumatic brain injury (TBI). Which of the following nursing interventions should be added to the plan of care? (Select All that Apply.)

Administer pain medication as needed.

Maintain ventriculostomy at the correct position.

Maintain the neck in the midline position.

Elevate the head of the bed to 150.

Maintain enteral feedings.

Answer and Explanation

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

A. Administer pain medication as needed. Rationale: Pain management is essential for clients with traumatic brain injury (TBI) to ensure their comfort and to prevent agitation or increased intracranial pressure (ICP) due to pain. Administering pain medication as needed helps alleviate discomfort and promotes rest, which supports the client's recovery.

B. Maintain ventriculostomy at the correct position. Rationale: Ventriculostomy, also known as an external ventricular drain (EVD), is a critical component of managing intracranial pressure (ICP) in clients with traumatic brain injury. Maintaining the ventriculostomy at the correct position ensures accurate monitoring and drainage of cerebrospinal fluid (CSF), which helps control ICP levels and prevents complications such as cerebral edema.

C. Maintain the neck in the midline position. Rationale: Keeping the neck in a midline position is essential for clients with traumatic brain injury to prevent further injury to the cervical spine. Proper alignment of the neck helps maintain spinal stability and reduces the risk of exacerbating any existing spinal cord injury, which may coexist with the traumatic brain injury.

D. Elevate the head of the bed to 30 degrees. Rationale: Elevating the head of the bed to 30 degrees is recommended for clients with traumatic brain injury to promote cerebral venous drainage and reduce intracranial pressure (ICP). This position helps optimize cerebral perfusion and minimizes the risk of cerebral edema, which can occur with increased ICP.

E. Maintain enteral feedings. Rationale: Nutritional support is crucial for clients with traumatic brain injury to support healing and recovery. Enteral feedings, such as tube feedings, may be necessary if the client is unable to consume adequate nutrition orally due to impaired swallowing or altered consciousness. Providing enteral feedings ensures the client receives essential nutrients to support tissue repair and prevent malnutrition-related complications during the recovery process.

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Correct Answer is A

Explanation

A. Decreased circulation to the kidneys: Post-cardiac arrest syndrome (PCAS) is a constellation of systemic ischemia/reperfusion injury responses that occur after return of spontaneous circulation (ROSC) following cardiac arrest. One of the manifestations of PCAS is decreased circulation to the kidneys due to the systemic hypoperfusion that occurs during cardiac arrest and the subsequent reperfusion injury that follows ROSC. This can lead to acute kidney injury (AKI) in some cases.

B. Increased mental capacity: While it is crucial to monitor neurological status after cardiac arrest, an immediate increase in mental capacity is not typically indicative of PCAS. Rather, neurological assessment may involve evaluating for signs of brain injury or dysfunction, which can include altered mental status, confusion, or neurological deficits.

C. Improving respiratory function: Improvement in respiratory function after cardiac arrest is a positive sign but may not necessarily indicate the development of PCAS. PCAS primarily involves systemic responses to the ischemia/reperfusion injury that occurs during and after cardiac arrest, rather than isolated respiratory changes.

D. Improvement in heart rate and blood pressure: Improvement in heart rate and blood pressure after cardiac arrest is generally expected with successful resuscitation efforts. However, these improvements alone may not necessarily indicate the development of PCAS. PCAS involves a broader range of systemic responses beyond just cardiac and hemodynamic changes.

A. Basketball, office jobs, and listening to loud music B. Swimming, working as a nurse, and painting C. Football, military service, and physical abuse D. Golfing, working in construction, and horse roping

Correct Answer is C

Explanation

A. Basketball, office jobs, and listening to loud music: These activities are not typically associated with an increased risk of chronic traumatic encephalopathy (CTE). While some recreational and occupational activities may involve physical or environmental risks, they are not commonly linked to the repetitive head trauma seen in CTE.

B. Swimming, working as a nurse, and painting: These activities are not commonly associated with an increased risk of CTE. Swimming is generally a low-risk activity for head injuries, while working as a nurse and painting are not typically associated with repetitive head trauma.

C. Football, military service, and physical abuse: This is the correct answer. Chronic traumatic encephalopathy (CTE) is strongly associated with repetitive head trauma, particularly in contact sports like football, as well as in military service where blast injuries and combat-related head trauma are common. Physical abuse, especially in contact sports, can also increase the risk of CTE due to repetitive blows to the head.

D. Golfing, working in construction, and horse roping: While some occupational and recreational activities may involve a risk of head injury, they are not commonly associated with the repetitive head trauma seen in CTE. Golfing, construction work, and horse roping typically do not involve the level of repetitive head impacts seen in activities like football or military service.

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A nurse is planning care for a client who has a traumatic brain injury (TBI). Which of the following nursing interventions should be added to the plan of care? (Select All that Apply.)

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