A nurse has received report on a client who has a basilar skull fracture. Which of the following findings should the nurse anticipate with this client?

Pooling of blood and edema around the eyes

Ability to recall how the injury occurred

Bruising over the mastoid process

Chvostek’s sign

Answer and Explanation

The Correct Answer is A

A. Pooling of blood and edema around the eyes: Basilar skull fractures can lead to leakage of cerebrospinal fluid (CSF) into the surrounding tissues, resulting in periorbital ecchymosis, also known as raccoon eyes, due to pooling of blood and edema around the eyes. This finding is characteristic of basilar skull fractures and is caused by disruption of the meninges and subsequent CSF leakage into the soft tissues of the face.

B. Ability to recall how the injury occurred: Memory loss regarding the events surrounding the injury, known as post-traumatic amnesia, is common with basilar skull fractures. This amnesia occurs due to the impact of the injury on the brain and may involve retrograde amnesia (loss of memory of events leading up to the injury) and anterograde amnesia (loss of memory of events occurring after the injury).

C. Bruising over the mastoid process: Bruising over the mastoid process, known as Battle sign, is associated with basilar skull fractures. Battle sign results from blood accumulation (hematoma) in the mastoid region behind the ear due to fracture-related injury to the middle meningeal artery or other blood vessels. This finding typically develops 24-48 hours after the injury.

D. Chvostek’s sign: Chvostek's sign is a clinical manifestation of hypocalcemia, not basilar skull fractures. It is elicited by tapping the facial nerve (facial nerve spasm) and is indicative of neuromuscular irritability due to decreased calcium levels. Chvostek's sign is not directly related to basilar skull fractures.

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Correct Answer is D

Explanation

A. "I should ask my son to drive me to the grocery store." This statement does not directly address the risk for sudden cardiac death associated with arrhythmogenic cardiomyopathy. While it may be a valid safety precaution to have someone else drive, it does not specifically address the client's understanding of the condition and its implications for sudden cardiac death.

B. "I will probably become easily constipated." Constipation is not a typical manifestation or complication of arrhythmogenic cardiomyopathy. This statement does not demonstrate an understanding of the condition and its associated risk of sudden cardiac death.

C. "I am aware that I may develop frequent hiccups." Frequent hiccups are not a characteristic symptom or complication of arrhythmogenic cardiomyopathy. This statement does not indicate an understanding of the condition and its risk for sudden cardiac death.

D. "I will need to avoid strenuous activity to prevent my heart from stopping." This statement reflects an understanding of the condition and its associated risk of sudden cardiac death. Strenuous activity can exacerbate arrhythmias in individuals with arrhythmogenic cardiomyopathy, potentially leading to life-threatening arrhythmias such as ventricular fibrillation. Avoiding strenuous activity is a recommended precaution to reduce the risk of sudden cardiac death in individuals with this condition.

A. "Since my parent suffered from Alzheimer's disease, I know that I am at an increased risk for developing the disease myself." B. "The cause of Alzheimer's disease is still not fully known or understood." C. "l do not have to worry about this because I do not have Down syndrome and I have never had a stroke." D. "My child is at risk for developing Alzheimer's disease because they have trisomy 21."

Correct Answer is C

Explanation

A. "Since my parent suffered from Alzheimer's disease, I know that I am at an increased risk for developing the disease myself." This statement is accurate. Family history is a significant risk factor for Alzheimer's disease. Individuals with a first-degree relative (such as a parent or sibling) with Alzheimer's disease are at a higher risk of developing the condition themselves.

B. "The cause of Alzheimer's disease is still not fully known or understood." This statement is also accurate. While there are theories about the underlying causes of Alzheimer's disease, such as genetics, brain changes, and environmental factors, the exact cause is still not fully understood. Research into the etiology of Alzheimer's disease is ongoing.

C. "I do not have to worry about this because I do not have Down syndrome and I have never had a stroke." This statement indicates a need for further teaching. While it is true that individuals with Down syndrome and those who have had a stroke are at increased risk for developing Alzheimer's disease, they are not the only populations at risk. Alzheimer's disease can affect individuals without Down syndrome or a history of stroke. Other risk factors include age, family history, genetics, and lifestyle factors.

D. "My child is at risk for developing Alzheimer's disease because they have trisomy 21." This statement is accurate. Trisomy 21, also known as Down syndrome, is associated with an increased risk of developing Alzheimer's disease. Individuals with Down syndrome have three copies of chromosome 21, which contains the gene for amyloid precursor protein (APP). Overproduction of amyloid beta protein, derived from APP, is thought to contribute to the development of Alzheimer's disease in individuals with Down syndrome.

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A nurse has received report on a client who has a basilar skull fracture. Which of the following findings should the nurse anticipate with this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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