A nurse is reviewing laboratory results for a client who has atrial fibrillation. Which of the following blood test results should the nurse understand can be a possible cause of atrial fibrillation?

Elevated erythrocyte sedimentation rate (ESR)

Elevated thyroid-stimulating hormone (TSH)

Elevated brain natriuretic peptide (BNP)

Elevated C-reactive protein (CRP)

Answer and Explanation

The Correct Answer is B

A. Elevated erythrocyte sedimentation rate (ESR): Elevated ESR indicates inflammation in the body and is not typically associated with the cause of atrial fibrillation.

B. Elevated thyroid-stimulating hormone (TSH): This is the correct answer. A common cause of atrial fibrillation is hyperthyroidism, which is characterized by an overactive thyroid gland and often presents with elevated TSH levels. Thyroid hormones play a significant role in regulating heart rate and rhythm. Excess thyroid hormone can lead to increased heart rate and irregular heart rhythms, including atrial fibrillation.

C. Elevated brain natriuretic peptide (BNP): Elevated BNP levels are associated with heart failure and may indicate cardiac stress or dysfunction. While heart failure can predispose individuals to atrial fibrillation, elevated BNP levels themselves are not a direct cause of atrial fibrillation.

D. Elevated C-reactive protein (CRP): Elevated CRP levels indicate inflammation in the body and are associated with various cardiovascular diseases. While inflammation can contribute to atrial fibrillation, elevated CRP levels alone are not a direct cause of atrial fibrillation.

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

Explanation

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.

A. Ask the client to move their eyes side to side while keeping their head still. B. Ask the client to breathe in through pursed lips. C. Ask the client to pull the pinna of their ears up and back. D. Ask the client to open their mouth widely.

Correct Answer is A

Explanation

A. Ask the client to move their eyes side to side while keeping their head still: This action helps assess if movement exacerbates the client's tinnitus. Tinnitus that worsens with eye movement suggests a potential vascular cause, as the blood vessels surrounding the auditory nerve may be affected. This maneuver is known as the Valsalva maneuver and can help identify vascular issues contributing to tinnitus.

B. Ask the client to breathe in through pursed lips: Breathing through pursed lips is a technique used to help manage shortness of breath and is not directly related to assessing tinnitus or its exacerbating factors.

C. Ask the client to pull the pinna of their ears up and back: Pulling the pinna of the ears up and back is a maneuver commonly performed during otoscopic examination to straighten the ear canal for better visualization of the tympanic membrane. It is not directly relevant to assessing tinnitus or its exacerbating factors.

D. Ask the client to open their mouth widely: Opening the mouth widely is not typically associated with exacerbating tinnitus. This action is more relevant for assessing temporomandibular joint (TMJ) dysfunction or other oral conditions but is not specific to tinnitus assessment.

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A nurse is reviewing laboratory results for a client who has atrial fibrillation. Which of the following blood test results should the nurse understand can be a possible cause of atrial fibrillation?

Nursing Test Bank

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Explanation

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Correct Answer is A

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