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What causes secondary brain injury after head trauma?
- A. Brain injury resulting from the body's response to tissue damage
- B. Brain injury resulting from initial trauma
- C. Injury as a result of medical therapy
- D. Focal areas of bleeding
Correct Answer: A
Rationale: The correct answer is A. Secondary brain injury occurs due to the body's response to the initial trauma, which can worsen the effects of the primary injury. This response includes processes like inflammation, increased intracranial pressure, and reduced oxygen delivery to tissues. Choice B is incorrect because it refers to the primary trauma itself, not the secondary injury. Choice C is incorrect as it relates to injury caused by medical interventions rather than the body's response. Choice D is incorrect as it specifically mentions focal areas of bleeding, which is a consequence of trauma rather than the cause of secondary brain injury.
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What are the characteristics of the inflammatory process?
- A. Loss of function, coolness
- B. Pain, redness
- C. Heat, pallor
- D. Swelling, pallor
Correct Answer: B
Rationale: The correct answer is B: Pain, redness. Inflammation is characterized by pain and redness as part of the body's response to tissue injury. Choice A, loss of function and coolness, are not primary characteristics of inflammation. Choice C, heat and pallor, may be present in some cases but are not as consistently associated with inflammation as pain and redness. Choice D, swelling and pallor, includes swelling which is common in inflammation but pallor is not a typical characteristic.
What does a client's symptoms of headache, vomiting, blurred vision, and loss of consciousness following a concussion indicate?
- A. Increased intracranial pressure
- B. Lower extremity compartment syndrome
- C. Consuming too much food at once
- D. Improved kidney function
Correct Answer: A
Rationale: The symptoms of headache, vomiting, blurred vision, and loss of consciousness following a concussion are indicative of increased intracranial pressure. These symptoms suggest a serious condition that can occur after head trauma, requiring immediate medical attention. Lower extremity compartment syndrome presents with symptoms related to pressure build-up in the muscles of the legs, not the head. Consuming too much food at once does not manifest with these neurological symptoms. Improved kidney function would not present with symptoms such as headache, vomiting, blurred vision, and loss of consciousness.
What is the primary function of the kidneys in acid-base balance?
- A. The kidneys remove hydrogen ions and retain bicarbonate ions.
- B. The kidneys convert ammonia into urea, which is excreted in the urine.
- C. The kidneys produce aldosterone to regulate sodium levels.
- D. The kidneys secrete renin to regulate blood pressure.
Correct Answer: A
Rationale: The correct answer is A. The kidneys are crucial in maintaining acid-base balance by removing hydrogen ions to decrease acidity and retaining bicarbonate ions to increase alkalinity. Choice B is incorrect because the conversion of ammonia into urea is related to nitrogen waste excretion, not acid-base balance. Choice C is incorrect as aldosterone regulates sodium levels, not acid-base balance. Choice D is also incorrect as renin is involved in regulating blood pressure, not acid-base balance.
Which of the following are characteristic, localized cardinal signs of acute inflammation? (Select ONE that does not apply.)
- A. Redness
- B. Fatigue
- C. Swelling
- D. Warmth
Correct Answer: B
Rationale: The correct answers are A, C, and D. Redness, swelling, and warmth are classic signs of acute inflammation. Redness occurs due to increased blood flow, swelling is caused by leakage of fluid into tissues, and warmth is due to the vasodilation and increased blood flow in the affected area. Fatigue is not a cardinal sign of acute inflammation and is not directly associated with the inflammatory response.
When administering azoles in the home setting, the home health nurse should prioritize educational interventions that address what nursing diagnosis?
- A. Risk for injury related to antifungal therapy
- B. Risk for acute confusion related to antifungal therapy
- C. Risk for infection related to antifungal therapy
- D. Risk for falls related to antifungal therapy
Correct Answer: A
Rationale: The correct answer is A: Risk for injury related to antifungal therapy. When administering azoles, the priority is to educate patients and caregivers about potential side effects that could lead to injury, such as hepatotoxicity or allergic reactions. Choices B, C, and D are incorrect because acute confusion, infection, and falls are not typically associated with azole therapy.