A nurse is reinforcing teaching to a group of nursing students about causes of traumatic brain injuries (TBIs). Which of the following should the nurse include in the teaching? (Select All that Apply)
Falls
Violence
Sports-related injuries
Working as a firefighter
Working in a factory
Correct Answer : A,B,C
A. Falls are one of the leading causes of TBIs, especially in older adults and young children.
B. Violence, including assaults or domestic abuse, can result in traumatic brain injuries, often due to blunt trauma to the head.
C. Sports-related injuries, particularly from contact sports like football or boxing, are a well-recognized cause of TBIs.
D. While firefighting can involve physical risks, it is not a direct cause of traumatic brain injuries unless an accident involving the head occurs.
E. Working in a factory, though it may pose various risks, does not typically involve causes directly linked to TBIs unless there is an accidental head injury.
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Correct Answer is B
Explanation
A. The ascending tracts transmit sensory information to the brain, but they do not process the information; that function is performed in the brain itself.
B. This statement accurately reflects the function of the descending tracts, which carry motor signals from the CNS to the muscles, facilitating voluntary movement.
C. Sensory receptors are located in various tissues throughout the body, including the skin and muscles, but not exclusively in the muscles.
D. Motor neurons are located in the spinal cord and peripheral nervous system, not in the dermal layer of the skin, where sensory receptors reside.
Correct Answer is D
Explanation
A. The nurse should measure the apical pulse for a full minute (not 30 seconds) before administering digoxin. If the pulse is below 60 beats per minute, the medication should be withheld, making this option incomplete.
B. Digoxin should be withheld if the heart rate is below 60/min, not above 100/min. This statement does not reflect proper nursing protocol.
C. Clients taking digoxin should maintain adequate potassium levels, so advising low potassium intake is incorrect. Foods rich in potassium are encouraged.
D. Monitoring for symptoms such as nausea, vomiting, and yellow vision is essential, as these may indicate digoxin toxicity, making this option correct.