A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first?

Decreased heart rate

Alteration in level of consciousness (LOC)

Slurred speech

Bradycardia

Answer and Explanation

The Correct Answer is B

Reasoning:

Choice A reason: Decreased heart rate is a late sign in subdural hematoma, occurring with increased intracranial pressure (ICP) causing Cushing’s triad (bradycardia, hypertension, irregular breathing). Early manifestations like altered LOC appear first due to hematoma compression, making heart rate changes a secondary concern.

Choice B reason: Alteration in level of consciousness is the earliest manifestation of subdural hematoma. As the hematoma expands, it compresses brain tissue, impairing cerebral function, leading to confusion, lethargy, or reduced responsiveness. This precedes other signs like motor deficits or vital sign changes, making it the first to monitor.

Choice C reason: Slurred speech may occur in subdural hematoma if motor or speech areas are affected, but it is not the earliest sign. Altered LOC typically precedes focal neurological deficits, as hematoma compression globally impacts brain function before specific areas, making speech changes secondary.

Choice D reason: Bradycardia, like decreased heart rate, is a late sign in subdural hematoma, part of Cushing’s triad from severe ICP elevation. Early signs like altered LOC occur first due to initial brain compression, making bradycardia a later manifestation requiring urgent intervention.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Reasoning:

Choice A reason: A blood pressure of 150/90 mm Hg is not an absolute contraindication for thrombolytic therapy. While hypertension must be controlled (below 185/110 mm Hg) before thrombolytics, it is manageable with medication, unlike hemorrhagic stroke, which poses an immediate and absolute risk of worsening bleeding.

Choice B reason: Previous thrombolytic therapy within 12 months is not an absolute contraindication. Guidelines restrict thrombolytics within a shorter timeframe (e.g., recent major surgery), but prior therapy alone does not preclude use. Hemorrhagic stroke is a definitive contraindication due to the risk of catastrophic bleeding.

Choice C reason: Evidence of hemorrhagic stroke is an absolute contraindication for thrombolytic therapy, as thrombolytics like tPA dissolve clots, increasing bleeding in an already hemorrhagic brain. This risks worsening intracranial hemorrhage, leading to neurological deterioration or death, making it a critical exclusion criterion.

Choice D reason: Evidence of stroke evolution, such as progressing symptoms, is not an absolute contraindication. It may influence timing or eligibility, but thrombolytics can still be used within the time window if ischemic. Hemorrhagic stroke is a definitive barrier due to bleeding risk.

A. Itching, rash, and jaundice B. Night sweats, weight loss, and diarrhea C. Dyspnea, tachycardia, and pallor D. Nausea, vomiting, and anorexia

Correct Answer is C

Explanation

Reasoning:

Choice A reason: Itching, rash, and jaundice are not typical of iron deficiency anemia. Jaundice suggests hemolysis or liver disease, and itching or rash may indicate allergic or dermatologic conditions. Iron deficiency causes reduced hemoglobin, leading to oxygen delivery issues, not these symptoms, making this incorrect.

Choice B reason: Night sweats, weight loss, and diarrhea suggest systemic conditions like malignancy or infection, not iron deficiency anemia. These symptoms are unrelated to low iron, which primarily causes fatigue and pallor due to reduced hemoglobin and oxygen-carrying capacity, not inflammatory or gastrointestinal symptoms.

Choice C reason: Dyspnea, tachycardia, and pallor are classic findings in iron deficiency anemia. Low hemoglobin reduces oxygen delivery, causing dyspnea and tachycardia as the body compensates. Pallor results from decreased red blood cell mass, reflecting the anemia’s impact on tissue oxygenation and circulation.

Choice D reason: Nausea, vomiting, and anorexia are not primary features of iron deficiency anemia. These gastrointestinal symptoms may occur with iron supplementation side effects or other conditions, but anemia itself causes fatigue, pallor, and dyspnea due to low hemoglobin, not digestive disturbances.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is brought by ambulance to the ED after experiencing what the family thinks is a stroke. The nurse caring for this client is aware that which is an absolute contraindication for thrombolytic therapy?

Correct Answer is C

Explanation

A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia?

Correct Answer is C

Explanation

A client with a neurological disorder has difficulty swallowing. The nurse should take special care with the client’s diet because of a potential risk of imbalanced nutrition. Which measure may be taken by the nurse to ensure that the client’s diet allows for easy swallowing?

The nurse is assessing a new client with reports of acute fatigue and a sore tongue that is visibly smooth and beefy red. This client is demonstrating signs and symptoms associated with what form of hematologic disorder?

Which clinical sign is associated with diabetes insipidus?

A client with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurse’s best intervention for preventing injury?

A client has been receiving a continuous infusion of weight-based heparin for more than 4 days. The client’s PTT is at a level that requires an increase of heparin by 100 units per hour. The client has the laboratory findings shown above. What is the most important action for the nurse to take?

A client has been taking tricyclic antidepressants for many years for the treatment of depression. The client has developed SIADH and has been admitted to the acute care facility. What should the nurse carefully monitor when caring for this client? (Select all that apply)

Which type of hemolytic anemia is categorized as an inherited disorder?

A client is being successfully treated for Cushing's syndrome. The nurse should expect a decline in: