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: Chvostek and Trousseau signs are not typically associated with hypothyroidism.
Choice B rationale: These signs are not commonly related to pineal tumors.
Choice C rationale: Chvostek and Trousseau signs, indicating neuromuscular irritability due to hypocalcemia, are often seen in hypoparathyroidism.
Choice D rationale: Chvostek and Trousseau signs are not characteristic findings in pheochromocytoma.
Correct Answer is B
Explanation
Choice A rationale: This is not correct since the picture depicted has uterine tissues deposited in other regions other than the uterus.
Choice B rationale: Endometriosis is a condition where tissue similar to the endometrium (the lining of the uterus) grows outside the uterus, such as on the ovaries, fallopian tubes, pelvic wall, or bowel. This tissue responds to hormonal changes and bleeds during the menstrual cycle, causing inflammation, pain, and sometimes infertility.
Choice C rationale: Leiomyomas, also known as fibroids, are benign tumors that develop from the smooth muscle cells of the uterus. They can vary in size, number, and location within or outside the uterus. They can cause symptoms such as heavy bleeding, pelvic pressure, pain, and infertility.
Choice D rationale: Adenomyosis is a condition where endometrial-like tissue grows within the muscular wall of the uterus (the myometrium). This tissue also bleeds during the menstrual cycle, causing the uterus to enlarge and become painful and heavy .
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