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.
A client is brought to the emergency department after a motor vehicle accident in which she suffered a spinal cord injury at the level of C5. Which of the following assessments should be the priority?
- A. Monitoring urinary output
- B. Monitoring heart rate and rhythm
- C. Monitoring respiratory rate
- D. Monitoring the client's pain levels
Correct Answer: B
Rationale: The correct answer is monitoring heart rate and rhythm. With a C5 spinal cord injury, monitoring heart rate and rhythm is crucial as it can impact autonomic regulation. This level of injury can affect cardiac function due to the disruption of sympathetic nerve fibers. Monitoring urinary output may be important to assess for urinary retention, but it is not the priority in this scenario. While monitoring respiratory rate is essential in all patients, in this case, cardiovascular stability takes precedence. Pain management is important but is not the priority when assessing a client with a C5 spinal cord injury.
What symptoms would the nurse expect to see in a client with chronic obstructive pulmonary disease (COPD)?
- A. Dyspnea on exertion
- B. Normal lung sounds
- C. Normal arterial blood gases
- D. Onset of the disease during young adulthood
Correct Answer: A
Rationale: The correct answer is A: Dyspnea on exertion. COPD typically manifests with symptoms like dyspnea on exertion due to impaired lung function. This symptom is a result of the airways being obstructed and the lungs not being able to expel air effectively. Choices B and C are incorrect because in COPD, abnormal lung sounds such as wheezing, crackles, or diminished breath sounds are often heard upon auscultation, and arterial blood gases are usually abnormal, showing low oxygen levels and high carbon dioxide levels. Choice D is incorrect as COPD is more commonly diagnosed in individuals over 40 who have a history of smoking or exposure to lung irritants.
A female client with bone metastases secondary to lung cancer is admitted for palliative radiation treatment and pain control. The client is currently experiencing pain that she rates at 9 out of 10. Which of the following nonpharmacologic treatments is most likely to be a useful and appropriate supplement to pharmacologic analgesia at this point?
- A. Teaching the client guided imagery and meditation
- B. Initiating neurostimulation
- C. Heat therapy
- D. Relaxation and distraction
Correct Answer: D
Rationale: In the scenario described, the client is experiencing high pain levels, rated at 9 out of 10. Relaxation and distraction techniques are effective nonpharmacologic interventions for managing pain. Teaching the client guided imagery and meditation (Choice A) can also be beneficial; however, in this acute situation of severe pain, relaxation and distraction techniques are more likely to provide immediate relief. Initiating neurostimulation (Choice B) and heat therapy (Choice C) may not be suitable for immediate pain relief in this scenario and are not as commonly used for managing high pain levels in palliative care settings.
A 21-year-old male is being started on zidovudine (AZT) for the treatment of HIV/AIDS. Which of the following statements made by the patient indicates that he has understood the patient teaching?
- A. "AZT inactivates the virus and prevents recurrence of the disease."
- B. "AZT therapy may result in the development of AZT-resistant strains."
- C. "AZT slows the progression of the disease but does not cure it."
- D. "AZT prevents the occurrence of opportunistic infections."
Correct Answer: C
Rationale: The correct answer is C. When the patient states, "AZT slows the progression of the disease but does not cure it," it shows an understanding that zidovudine (AZT) does not provide a cure for HIV/AIDS but helps in slowing down the progression of the disease. Choice A is incorrect because AZT does not inactivate the virus or prevent recurrence. Choice B is incorrect as AZT resistance can develop with therapy. Choice D is incorrect because while AZT can help prevent opportunistic infections by boosting the immune system, its primary action is not the prevention of opportunistic infections.