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: Phenelzine is an antidepressant that typically does not affect blood glucose levels significantly.
Choice B rationale: Allopurinol, used for gout, is not known to significantly impact blood glucose levels.
Choice C rationale: Metoprolol, a beta-blocker, might mask some symptoms of hypoglycemia but is not typically associated with causing hyperglycemia.
Choice D rationale: Methylprednisolone, a corticosteroid, can elevate blood glucose levels and might contribute to hyperglycemia in a person with diabetes mellitus.
Correct Answer is B
Explanation
Choice A rationale: PCOS is not typically associated with genetic cancerous mutations.
Choice B rationale: Insulin resistance and hyperinsulinemia are commonly associated with PCOS, contributing to its pathophysiology.
Choice C rationale: While cortisol abnormalities can cause similar symptoms, it's not a primary finding in PCOS.
Choice D rationale: PCOS often involves hormonal imbalances, but it's not characterized by an estrogen deficit.
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