A nurse is planning care for a client who has increased intracranial pressure. The nurse should understand that enteral nutrition should begin within 24 to 48 hr to help prevent which of the following complications?

Myocardial infarction

Bacterial translocation

Pulmonary embolus

Deep vein thrombosis

Answer and Explanation

The Correct Answer is B

A. Myocardial infarction: Enteral nutrition initiation within 24 to 48 hours is not directly associated with preventing myocardial infarction. While proper nutrition is important for overall cardiovascular health, the timing of enteral nutrition initiation primarily focuses on preventing complications related to increased intracranial pressure (ICP).

B. Bacterial translocation: Initiating enteral nutrition within 24 to 48 hours in clients with increased intracranial pressure helps prevent complications such as bacterial translocation. Bacterial translocation refers to the passage of bacteria from the gastrointestinal tract into the bloodstream and systemic circulation. Delayed initiation of enteral nutrition can lead to intestinal mucosal breakdown and increased intestinal permeability, facilitating bacterial translocation. Early enteral nutrition helps maintain intestinal mucosal integrity, reduces gut bacterial overgrowth, and decreases the risk of bacterial translocation, thereby lowering the risk of infectious complications.

C. Pulmonary embolus: Initiating enteral nutrition within 24 to 48 hours is not directly associated with preventing pulmonary embolus. Pulmonary embolism is a complication characterized by the obstruction of pulmonary arteries by blood clots, typically originating from deep vein thrombosis. Prevention of pulmonary embolus involves measures such as early mobilization, pharmacological prophylaxis, and mechanical compression devices to prevent venous stasis and thrombus formation.

D. Deep vein thrombosis: Initiating enteral nutrition within 24 to 48 hours is not directly associated with preventing deep vein thrombosis. Deep vein thrombosis is a complication characterized by the formation of blood clots within deep veins, commonly in the lower extremities. Prevention of deep vein thrombosis involves measures such as early mobilization, pharmacological prophylaxis, and mechanical compression devices to prevent venous stasis and thrombus formation.

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Correct Answer is B

Explanation

A. Severe myopia: Severe myopia, or nearsightedness, is not a typical manifestation of Meniere's disease. Meniere's disease primarily affects the inner ear and is characterized by symptoms related to balance and hearing rather than vision.

B. Vertigo: Meniere's disease is a disorder of the inner ear that causes episodes of vertigo, which is a sensation of spinning or dizziness. Vertigo is a hallmark symptom of Meniere's disease and is often accompanied by nausea, vomiting, and a feeling of fullness or pressure in the affected ear.

C. Anosmia: Anosmia refers to a loss of the sense of smell and is not typically associated with Meniere's disease. Meniere's disease primarily affects the vestibular system (balance) and auditory system (hearing) rather than the sense of smell.

D. Photopsia: Photopsia refers to the perception of flashes of light in the visual field and is not a typical manifestation of Meniere's disease. Meniere's disease primarily affects the inner ear and is not directly related to visual disturbances.

A. The client who is out of work and has been experiencing increased stress. B. The client who is recovering from a recent illness that caused vomiting and diarrhea. C. The client whose mother and uncle were diagnosed with this same condition. D. The client who had a myocardial infarction and required stent placement.

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.

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A nurse is planning care for a client who has increased intracranial pressure. The nurse should understand that enteral nutrition should begin within 24 to 48 hr to help prevent which of the following complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has Meniere’s disease. Which of the following manifestations should the nurse expect?

Correct Answer is B

Explanation

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

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