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 A
Explanation
A. A positive result in a Tensilon test is indicated by a temporary improvement in muscle strength following the administration of edrophonium (Tensilon), confirming the diagnosis of myasthenia gravis.
B. A "pill-rolling" tremor is associated with Parkinson's disease, not myasthenia gravis, and is not relevant to this test.
C. While muscle electrical activity can be assessed in other tests, the Tensilon test specifically evaluates muscle strength changes, not electrical charge intensity.
D. No change in muscle strength would suggest a negative result for myasthenia gravis, indicating that the test did not confirm the diagnosis.
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.