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 C
Explanation
Choice A rationale: BSE will not reduce the risk of dying from breast cancer, but it may help you detect breast cancer earlier, when it is more treatable.
Choice B rationale: BSE should be done once a month, preferably at the same time each month. For women who have menstrual periods, the best time to do BSE is a few days after the period ends, when the breasts are less tender and swollen. For women who do not have menstrual periods, such as those who are pregnant, breastfeeding, or postmenopausal, they can choose a fixed date, such as the first day of each month, to do BSE.
Choice C rationale: For women who have menstrual periods, the best time to do BSE is a few days after the period ends, when the breasts are less tender and swollen. For women who do not have menstrual periods, such as those who are pregnant, breastfeeding, or postmenopausal, they can choose a fixed date, such as the first day of each month, to do BSE.
Choice D rationale: Annual mammograms are recommended for women aged 40 and older, or earlier if they have a high risk of breast cancer and not all women. Women aged less than 30 years should undergo breast ultrasound instead.
Correct Answer is D
Explanation
Choice A rationale: Hormone therapy (HT) is used to treat menopausal symptoms, not PID.
Choice B rationale: Irregularities in the menstrual cycle is not a common complications of PID.
Choice C rationale: Changes in secondary sex characteristics is not a common complications of PID.
Choice D rationale: Pelvic inflammatory disease (PID) is an infection of the female reproductive organs that can cause scarring and damage to the fallopian tubes, ovaries, and uterus. This can lead to ectopic pregnancy, chronic pelvic pain, and infertility.
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