when caring for a client with traumatic brain injury tbi who had a craniotomy for increased intracranial pressure icp the nurse assesses the client us when caring for a client with traumatic brain injury tbi who had a craniotomy for increased intracranial pressure icp the nurse assesses the client us
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Nursing Elites

HESI RN

HESI RN Exit Exam 2024 Quizlet

1. When caring for a client with traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow Coma Scale (GCS) every two hours. For the past 8 hours, the client's GCS score has been 14. What does this GCS finding indicate about the client?

Correct answer: A

Rationale: A GCS score of 14 indicates that the client is neurologically stable without indications of increased ICP. It suggests that the client's neurological status is relatively intact, with only mild impairment, if any. This finding reassures the nurse that there are currently no signs of deterioration or immediate need for intervention. Choice B is incorrect because a GCS score of 14 does not necessarily indicate immediate risk for neurological deterioration. Choice C is incorrect as mild cognitive impairment is not typically inferred from a GCS score of 14. Choice D is incorrect as immediate medical intervention is not warranted based on a GCS score of 14 without other concerning symptoms.

2. Which bioterrorism agent is at high risk for use as a potential biological weapon that is readily transmitted by several portals of entry?

Correct answer: A

Rationale: Anthrax is the correct answer. Anthrax spores can be transmitted through inhalation, ingestion, or skin contact, making it a high-risk agent for bioterrorism. Smallpox, botulism, and tularemia are also potential bioterrorism agents, but they do not have the same versatility in terms of multiple portals of entry, unlike anthrax.

3. A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is?

Correct answer: D

Rationale: In clients with altered renal function being treated at home, weekly weight is the most accurate indicator of fluid balance. Fluid retention or loss can significantly affect weight, making it a reliable measure. Choices A, B, and C are not as accurate indicators of fluid balance as weekly weight. Intake and output differences can vary in accuracy and may not capture all aspects of fluid balance. Changes in mucous membranes and skin turgor can be influenced by factors other than fluid balance, making them less precise indicators.

4. To ensure the provision of appropriate services for overcoming infertility barriers to the achievement of reproductive intentions, Integrated Reproductive Health has incorporated a component of:

Correct answer: A

Rationale: The correct answer is A: Infertility. Integrated Reproductive Health incorporates a component focused on infertility to address barriers to achieving reproductive intentions. This inclusion is crucial as infertility can be a significant obstacle to reproductive health. Choice B, safe abortions, is incorrect as it is not directly related to overcoming infertility barriers. Choice C, STIs and HIV, while important for reproductive health, is not specifically addressing infertility. Choice D, family planning, although relevant for reproductive health, is not the primary focus when addressing infertility barriers.

5. Practices such as female genital mutilation and unsafe male circumcision are categorized as:

Correct answer: A

Rationale: Practices like female genital mutilation and unsafe male circumcision are considered harmful traditional practices due to the physical and psychological harm they cause. Choice A is correct as these practices are not safe or recommended. Choice B is incorrect, as harmful traditional practices are not encouraged anywhere. Choice C is incorrect as modern surgery and organizations like IRH aim to eliminate such practices, not recommend them. Choice D is incorrect as these practices are not related to safer sex practices but rather harmful practices that need to be eradicated.

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