The nurse is assessing a teenager recently admitted with a severe concussion from playing football. Which is the most important nursing assessment to detect early signs of a declining condition?

Level of consciousness.

Focal neurological exam.

Body posturing.

Vital signs.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Assessing the level of consciousness is the most important nursing assessment for detecting early signs of a declining condition in a patient with a severe concussion. Changes in consciousness can indicate worsening brain injury or increased intracranial pressure, and prompt recognition is crucial for timely intervention.

Choice B reason:

A focal neurological exam is important but is more specific to identifying localized neurological deficits rather than detecting general deterioration. It is essential but secondary to monitoring the overall level of consciousness.

Choice C reason:

Body posturing can indicate severe brain injury or increased intracranial pressure, but it typically occurs later in the course of deterioration. Early changes in the level of consciousness are more sensitive indicators of a declining condition.

Choice D reason:

Vital signs are important to monitor, but changes in vital signs can occur later in the progression of a declining neurological status. Early detection of changes in the level of consciousness allows for more timely intervention.

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

Explanation

Choice A reason:

Autonomic dysreflexia is a serious condition that can occur in individuals with spinal cord injuries, particularly those at or above the T6 level. It is a secondary injury mechanism that results from the autonomic nervous system's abnormal response to stimuli below the level of injury, leading to severe hypertension and other complications.

Choice B reason:

Ischemia, or reduced blood flow, is a common cause of secondary injury following a spinal cord injury. It can result from initial trauma or subsequent swelling and vascular damage, leading to further cell death and tissue damage.

Choice C reason:

Edema, or swelling, is another cause of secondary injury in spinal cord injuries. The inflammatory response to injury can cause fluid accumulation, increasing pressure within the spinal column and exacerbating damage to spinal cord tissues.

Choice D reason:

Axial loading is a primary mechanism of spinal cord injury, not a secondary injury cause. It refers to the vertical force applied along the axis of the spine, typically resulting from falls or direct blows, leading to compression and potential fractures.

Choice E reason:

Hemorrhage, or bleeding, is a significant cause of secondary injury in spinal cord trauma. It can result from blood vessel damage at the injury site, leading to increased pressure, further tissue damage, and impaired blood flow.

A. The patient is coughing B. The ETT has a cuff leak C. The ventilator tubing has become disconnected D. The patient is complaining of a headache 8/10 pain

Correct Answer is A

Explanation

Choice A reason:

The patient coughing is the most likely cause of the high pressure alarm on a mechanical ventilator. Coughing can increase airway resistance and pressure, triggering the alarm. This is a common occurrence and should be addressed by assessing the patient's need for suctioning or other interventions to relieve the cough.

Choice B reason:

An endotracheal tube (ETT) cuff leak would typically cause a low pressure alarm, not a high pressure alarm. A cuff leak results in a loss of pressure within the ventilator circuit, leading to insufficient ventilation and a different alarm response.

Choice C reason:

If the ventilator tubing becomes disconnected, it would result in a low pressure alarm due to the loss of circuit integrity. A disconnection is a serious issue that needs immediate correction but does not cause high pressure alarms.

Choice D reason:

The patient's complaint of a headache does not directly relate to a high pressure alarm on the ventilator. While patient discomfort should always be addressed, it is not the most likely cause of the alarm in this scenario.

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The nurse is assessing a teenager recently admitted with a severe concussion from playing football. Which is the most important nursing assessment to detect early signs of a declining condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nursing student studying spinal cord injury recognizes all of the following to be causes of secondary injuries:

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

Explanation

The nurse is caring for a patient who is on mechanical ventilation and the high pressure alarm is sounding. Which of the following is the most likely cause?

Correct Answer is A

Explanation

To evaluate the effectiveness of mannitol, the nurse should monitor:

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