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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
All of the following should be included in the teaching:
A. Living a sedentary lifestyle: Sedentary behavior, characterized by physical inactivity, is a risk factor for various cardiovascular conditions, including atrial fibrillation. Regular exercise is important for maintaining heart health and reducing the risk of atrial fibrillation.
B. Family history of atrial fibrillation: A family history of atrial fibrillation increases an individual's risk of developing the condition. Genetic factors play a role in predisposing individuals to atrial fibrillation, and having a close relative with the condition can elevate one's risk.
C. History of thyroid disease: Thyroid disorders, particularly hyperthyroidism (overactive thyroid), are associated with an increased risk of atrial fibrillation. Thyroid hormones influence heart rate and rhythm, and imbalances can predispose individuals to atrial fibrillation.
D. Recent influenza infection: Infections, particularly respiratory infections such as influenza, can trigger episodes of atrial fibrillation in susceptible individuals. The inflammatory response and physiological stress associated with infections can disrupt normal heart rhythm and precipitate atrial fibrillation episodes.
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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