A new client has been received into the emergency department following a pedestrian-automobile collision. The triage nurse recognizes which of the following as an emergency and correctly notifies the provider immediately?
Clear, watery drainage from the ear.
Enlarged post-auricular lymph nodes.
Odorless, brown cerumen in the ear.
White spots on the tympanic membrane.
The Correct Answer is A
Choice A reason: Clear, watery ear drainage post-collision suggests cerebrospinal fluid (CSF) leak from a skull fracture. This urgent finding risks infection or brain injury, warranting immediate provider notification for imaging and intervention in this trauma case accurately.
Choice B reason: Enlarged post-auricular nodes may indicate infection, not an acute emergency. Post-trauma, this is less critical than potential CSF leak, making it a lower priority for immediate provider action in this collision scenario fully here.
Choice C reason: Odorless, brown cerumen is normal earwax, not an emergency. After a collision, this benign finding doesn’t signal trauma-related urgency, excluding it from requiring prompt provider notification compared to more severe signs entirely here.
Choice D reason: White tympanic membrane spots suggest scarring or infection, not immediate danger. Post-collision, this lacks the acuity of CSF leak, rendering it non-emergent and less urgent for provider attention in this context comprehensively here.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Trigeminal neuralgia causes sharp, intermittent facial pain lasting minutes due to cranial nerve V irritation. Normal vitals and no systemic symptoms align with this neuropathic condition, distinguishing it from inflammatory or vascular headache causes in this presentation.
Choice B reason: Meningitis presents with fever, neck stiffness, and severe headache, not intermittent facial pain. Normal temperature and vitals here rule out this acute infection, which affects meninges broadly, not just facial nerves, making it an unlikely fit.
Choice C reason: Migraines involve throbbing head pain, often with nausea or photophobia, lasting hours, not minutes of facial pain. The client’s brief, episodic description and normal vitals don’t match migraine’s typical systemic or prolonged profile, excluding it here.
Choice D reason: TMJ dysfunction causes jaw pain, often with chewing difficulty or joint sounds, not intermittent facial pain alone. Normal vitals and no joint-specific complaints suggest this isn’t TMJ-related, pointing instead to a neural origin like trigeminal neuralgia.
Correct Answer is B
Explanation
Choice A reason: Family history suggests dementia, not delirium. Dementia progresses slowly, unlike delirium’s acute onset, making this less indicative of the sudden cognitive shift typical of delirium, especially without a rapid trigger in this case fully here.
Choice B reason: New medication often causes delirium in older adults via anticholinergic effects or toxicity. This acute, reversible change aligns with delirium’s hallmark sudden onset, making it the most suggestive finding for this cognitive impairment accurately here.
Choice C reason: Decline over months to a year fits dementia, not delirium. Delirium is acute, not chronic, excluding this gradual progression as a sign of the rapid cognitive shift delirium presents in this assessment entirely and fully.
Choice D reason: Hypertension risks vascular dementia, not delirium. It’s a chronic factor, not an acute trigger, missing delirium’s sudden, reversible nature tied to immediate causes like drugs, rendering it less relevant here comprehensively and clearly.
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