A client admitted after a motor vehicle accident arrives with a Glasgow coma score (GCS) of 14 with a mild headache. 4 hours later, the client's GCS has decreased to 10, and now has a dilated pupil on the left side. Which of the following acute traumatic brain injuries does the nurse suspect the client has suffered?

Laceration

Acute subdural hematoma

Intracerebral hemorrhage

Epidural hematoma

Answer and Explanation

The Correct Answer is D

Choice A reason: This is incorrect because laceration is not an acute traumatic brain injury, but a type of wound that involves tearing or cutting of the skin or other tissues. Laceration can occur as a result of a motor vehicle accident, but it does not cause changes in the GCS or pupil size. The nurse should assess the client's skin for any signs of laceration, such as bleeding, swelling, or infection.
Choice B reason: This is incorrect because acute subdural hematoma is not likely to cause a dilated pupil on the left side. Acute subdural hematoma is a type of traumatic brain injury that involves bleeding between the dura mater and the arachnoid mater, which are two layers of the meninges that cover the brain. An acute subdural hematoma can cause a rapid decrease in the GCS, but it usually causes a dilated pupil on the same side as the injury, not on the opposite side.
Choice C reason: This is incorrect because intracerebral hemorrhage is not likely to cause a dilated pupil on the left side. Intracerebral hemorrhage is a type of traumatic brain injury that involves bleeding within the brain tissue itself. Intracerebral hemorrhage can cause a gradual decrease in the GCS, but it usually causes neurological deficits that correspond to the location of the bleeding, such as weakness, numbness, or aphasia, not pupillary changes.
Choice D reason: This is correct because epidural hematoma can cause a dilated pupil on the left side. Epidural hematoma is a type of traumatic brain injury that involves bleeding between the dura mater and the skull. Epidural hematoma can cause a lucid interval, which is a period of normal consciousness followed by a sudden decrease in the GCS, and a dilated pupil on the opposite side of the injury, due to compression of the third cranial nerve. The nurse should notify the provider immediately and prepare for emergency surgery.

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Correct Answer is B

Explanation

Choice A reason: This is incorrect because loss of peripheral vision is not a manifestation of cataracts, but of glaucoma. Glaucoma is a condition that causes increased pressure inside the eye and damage to the optic nerve, which can lead to loss of vision in the outer edges of the visual field. The nurse should assess the client's intraocular pressure and visual field test results to rule out glaucoma.
Choice B reason: This is correct because a decreased ability to perceive colors is a manifestation of cataracts. Cataracts are a condition that causes clouding or opacity of the lens, which is the transparent structure behind the pupil that focuses light onto the retina. Cataracts can reduce the clarity and contrast of vision and make colors appear faded or yellowish. The nurse should ask the client about any changes in color perception or brightness of objects.
Choice C reason: This is incorrect because loss of central vision is not a manifestation of cataracts but of macular degeneration. Macular degeneration is a condition that affects the macula, which is the central part of the retina that is responsible for sharp and detailed vision. Macular degeneration can cause blurred or distorted central vision, difficulty reading or recognizing faces, or dark spots in the visual field. The nurse should assess the client's visual acuity and fundoscopic examination results to rule out macular degeneration.
Choice D reason: This is incorrect because seeing bright flashes of light and floaters is not a manifestation of cataracts but of retinal detachment. Retinal detachment is a condition that occurs when the retina, which is the layer of tissue at the back of the eye that converts light into nerve impulses, separates from its underlying support tissue. Retinal detachment can cause sudden flashes of light, floaters, or shadows in the visual field. The nurse should refer the client to an ophthalmologist immediately if retinal detachment is suspected.

A. Hearing loss B. Tinnitus C. Pruritus D. Muffled sounds

Correct Answer is A

Explanation

Choice A reason: This is correct because hearing loss is the most common complaint associated with a problem involving the inner ear. The inner ear consists of the cochlea, which is the organ of hearing, and the vestibular system, which is the organ of balance. The inner ear converts sound waves into nerve impulses that are sent to the brain. Any damage or dysfunction of the inner ear can impair hearing and cause hearing loss.
Choice B reason: This is incorrect because tinnitus is not the most common complaint associated with a problem involving the inner ear, but rather a symptom that can occur with various ear problems. Tinnitus is a ringing, buzzing, or hissing sound in the ears that is not caused by an external source. Tinnitus can be caused by exposure to loud noise, ear infections, earwax buildup, aging, or certain medications, but it is not specific to the inner ear.
Choice C reason: This is incorrect because pruritus is not a complaint associated with a problem involving the inner ear, but rather a complaint associated with a problem involving the outer ear. Pruritus is itching of the skin that can be caused by dryness, irritation, infection, or allergy. Pruritus can affect the outer ear, which is the visible part of the ear that collects and directs sound waves into the ear canal, but it has no relation to the inner ear.
Choice D reason: This is incorrect because muffled sounds are not a complaint associated with a problem involving the inner ear, but rather a complaint associated with a problem involving the middle ear. Muffled sounds are sounds that are unclear or distorted due to reduced sound transmission or perception. Muffled sounds can be caused by fluid buildup, inflammation, infection, or perforation of the eardrum in the middle ear, which is the air-filled space between the eardrum and the inner ear that contains three tiny bones that amplify sound vibrations.

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Naxlex Comprehensive Predictor Exams

A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. Which of the following findings is consistent with manifestations of cataracts?

Correct Answer is B

Explanation

A client is diagnosed with a problem involving the inner ear. Which is the most common client complaint associated with a problem involving this part of the ear?

Correct Answer is A

Explanation

A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines, the nurse should document burns to which percentage of the client's total body surface area (TBSA)?

The client inquires what the positive result from the potassium hydroxide (KOH) test indicates. Which of the following is an accurate response by the nurse?

A nurse is teaching a class about physiological changes to hearing in older adult clients. Which of the following should the nurse include?

A client admitted with an acute exacerbation of Ménière's disease asks the student nurse why he was prescribed diphenhydramine. Which response by the student nurse requires correction by the primary nurse?

A client with red scaling papules on his elbows, knees, lower back, and scalp arrives to the clinic. Which of the following questions will the nurse include in her assessment?

A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider?

A nurse is performing a focused assessment for vision on a client suspected of having vision loss. Which cranial nerve is the nurse assessing when determining if there are visual field or visual acuity deficits?

The caregiver of an elderly client asks the nurse what can be done about the chronic bilateral inflammation of the eyelid margins that keeps recurring. Which of the following is the information that the nurse will provide?