A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further?
A scalp laceration oozing blood.
Dizziness, nausea, and transient confusion.
Headache rated "8" on a 0-10 scale.
Serosanguineous nasal drainage.
The Correct Answer is D
Choice A rationale: This is a possible sign of TBI but is not necessarily indicative of a life- threatening condition.
Choice B rationale: This is a possible sign of TBI but is not necessarily indicative of a life- threatening condition.
Choice C rationale: This is a possible sign of TBI but is not necessarily indicative of a life- threatening condition.
Choice D rationale: Serosanguineous nasal drainage (a mixture of blood and clear fluid) may suggest a basilar skull fracture, which is a fracture of the base of the skull that can damage vital structures such as the brainstem, cranial nerves, or major blood vessels. This can lead to serious complications such as meningitis, cerebrospinal fluid leak, or hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: The combination treats gonorrhea and chlamydia but not trichomonas.
Choice B rationale: While important, this combination aims to treat multiple potential infections, not solely prevent reinfection.
Choice C rationale: The dual therapy doesn’t cover syphilis; it's specifically targeted for gonorrhea and chlamydia.
Choice D rationale: Azithromycin covers both gonorrhea and chlamydia, so the combination ensures coverage for both possible infections.
Correct Answer is B
Explanation
Choice A rationale: Cerebral motor cortex primarily controls voluntary movements, not autonomic functions like respiration, heart rate, and blood pressure.
Choice B rationale: The brain stem controls vital functions like respiration, heart rate, and blood pressure, so damage to this area can lead to difficulties in these functions.
Choice C rationale: Broca's area is responsible for speech production and is not directly involved in autonomic functions.
Choice D rationale: The occipital lobe is primarily associated with visual processing and perception, not autonomic functions like respiration or heart rate.
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