A nurse is caring for four clients who might be brain dead. Which client would best meet the criteria to allow assessment of brain death?
a. Client with a core temperature of 95 ° F (35 ° C) for 2 days
b. Client in a coma for 2 weeks from a motor vehicle crash
c. Client who is found unresponsive in a remote area of a field by a hunter
d. Client with a systolic blood pressure of 92 mm Hg since admission
ANS: B
In order to determine brain death, clients must meet four criteria: 1) coma from a known cause, 2) normal or near-normal core temperature, 3) normal systolic blood pressure, and 4) at least one neurologic examination. The client who was in the car crash meets two of these criteria. The clients with the lower temperature and lower blood pressure have only one of these criteria. There is no data to support assessment of brain death in the client found by the hunter.
You might also like to view...
A nurse is volunteering at a local retirement community. She is attempting to organize a walking program. A resident asks, "Why should I exercise at my age?" What is the best response by the nurse?
A) "Exercise has not been shown have any benefits for people over 80." B) "Exercise can help reduce the negative effects of stress, which can impact your physical health." C) "Exercise can help increase your blood pressure." D) "You aren't too old to exercise."
You are caring for a 69-year-old patient who has just been admitted to your unit. The patient asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). What is the best response by the nurse?
A) "OA is a considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." B) " OA and RA are very similar. OA affects the smaller joints, and RA affects the larger, weight-bearing joints." C) "OA affects joints on both sides of the body. RA is usually unilateral." D) "OA is more common in women. RA is more common in men."
The practical/vocational nursing student is assigned the task of helping a new mother and father learn to bathe their newborn. The instructor asks the student how the session went, and the student replies, "The mother seemed to understand everything
She smiled and nodded at everything I told her. The father watched and didn't ask any questions." The instructor comments, "Without validation, you can't be sure." Which statements contributed to the instructor's knowledge on which to base the comment to the student? (Select all that apply.) a. Women nod to show that they are listening. b. Men ask fewer questions than women. c. Women smile to establish rapport. d. Nonverbal communication is a good indicator of understanding.
When taking penicillin, patients should be educated to notify the physician if a rash, fever, or chills occur because they may indicate a(n) ________.
Fill in the blank(s) with the appropriate word(s).