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.

Answer and Explanation

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.

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Correct Answer is ["A","C","E"]

Explanation

Choice A rationale: Correct. The statement is accurate because developing confusion could be a sign of a serious condition like severe electrolyte imbalance or dehydration, requiring immediate medical attention.

Choice B rationale: Incorrect. Fluid intake should not be arbitrarily limited without medical advice, especially for a client with diabetes insipidus. Maintaining a consistent fluid intake is crucial, and any changes should be guided by a healthcare provider.

Choice C rationale: Correct. Weighing oneself at the same time every day is a good practice for monitoring fluid balance and identifying sudden changes that may indicate a problem.

Choice D rationale: Incorrect. Desmopressin doses should be administered as prescribed. The medication's administration should be consistent with the healthcare provider's instructions or the medication guide, not arbitrarily altered.

Choice E rationale: Correct. Keeping a log of fluid intake and urine output is important for managing diabetes insipidus effectively and allows for informed adjustments in fluid intake or medication dosage.

Choice F rationale: Incorrect. Adjusting medication dosage without consulting a healthcare provider is not safe. While increased urination is a symptom of diabetes insipidus, the client should consult their healthcare provider if their symptoms persist or worsen, rather than self-adjusting the medication dose.

A. Impaired urinary elimination related to obstructed flow of urine. B. Acute pain related to obstruction by the stone. C. Risk for urinary sepsis related to urinary stasis. D. Deficient knowledge related to need for prevention of recurrence of calculi.

Correct Answer is D

Explanation

Choice A rationale: Addressing the obstruction and restoring urinary flow is a priority to prevent complications.

Choice B rationale: Managing pain caused by the stone obstruction is essential for the client's comfort and well-being.

Choice C rationale: Preventing urinary stasis and subsequent infection is crucial to avoid sepsis.

Choice D rationale: Education about prevention, though important, might have a lower priority compared to addressing immediate complications like obstruction and pain.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The home health nurse visits a client with chronic diabetes insipidus: Exhibits Which three (4) client statements would indicate a correct understanding of the teaching?

Correct Answer is ["A","C","E"]

Explanation

When planning care for a client with right ureteral renal calculi, which of the following nursing diagnosis has the less priority of care while caring for this patient?

Correct Answer is D

Explanation

A nurse is developing a plan of care for a client with a new diagnosis of Graves' disease. Which of the following interventions does the nurse include in the plan of care?

The nurse in the women's health clinic has four patients who are waiting to be seen. Which patient should the nurse see first?

A client with diffuse axonal injury is experiencing difficulty with respiration, heart rate, blood pressure. Which region of the brain does the nurse suspect to be affected?

The nurse assesses a client with damage to cranial nerve III. Which finding would be expected?

Which of the following imagine the nurse will recognize as a positive evidence of adenomyosis?

Which of the following patients is most likely experiencing Hyperglycemic Hyperosmolar Nonketotic Syndrome based on their symptoms?

The nurse is performing an assessment of a client with possible plantar fasciitis in the right foot. What assessment finding would the nurse expect in the right foot?

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