Y.W. is a 23-year-old male student from Thailand studying electrical engineering at the university. He was
ejected from a moving vehicle, which was traveling at 70 mph.
His injuries included a severe closed head
injury with an occipital hematoma, bilateral wrist fractures, and a right pneumothorax. During his neu
rologic intensive care unit (NICU) stay, Y.W. was intubated and placed on mechanical ventilation, had a
feeding tube inserted and was placed on tube feedings, had a Foley catheter placed, and had a central
venous catheter (CVC) inserted for medication administration.
Differentiate between primary and secondary head injury.
A primary head injury is the initial tissue damage resulting from the traumatic impact. It can include
the scalp, skull, or brain tissue itself. A secondary head injury complicates the primary injury and
causes further damage, resulting in a worse outcome or increased risk of death. Secondary injuries
include intracranial hemorrhage, cerebral edema, increased intracranial pressure (ICP), hypoxic
(ischemic) brain damage, and infection.
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Fill in the blank(s) with correct word
The client with diarrhea asks the nurse what he can eat, since every time he eats he has more watery stools. The nurse provides the following information:
A) "It would be best to give your bowel a rest and not eat anything for 24 hours." B) "Try the 'BRAT' diet: bouillon soup, rice, applesauce, and tea." C) "Soft-boiled eggs and toast for several days should help." D) "You need to talk to the dietician about that."
The mother of a 10-month-old infant tells the nurse that her infant "really likes cow's milk.". Which is the best response to this mother?
a. "Milk is good for him.". b. "It is best to wait until he is a year old before giving him cow's milk.". c. "Limit cow's milk to his bedtime bottle.". d. "Mix his cereal with cow's milk and give him formula in a bottle.".
A female client is concerned that she has not had sexual intercourse with her husband for over 2 months. Which of the following can the nurse respond as causes for an alteration in sexual functioning? (Select all that apply.)
1. Chronic illnesses 2. Physical disabilities 3. Negative body image 4. Medications 5. Surgical procedures 6. Employment status