A nurse in an emergency department is providing care for a client who has a subdural hematoma. The nurse should identify that which of the following is the earliest manifestation of a change in neurological status?

Severe headache.

Bradycardia.

Widened pulse pressure.

Change in level of consciousness.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Severe headache can be a symptom of a subdural hematoma, but it is not the earliest manifestation of a change in neurological status. Other symptoms may appear before a severe headache, such as an altered level of consciousness.

Choice B rationale:

Bradycardia can occur with a subdural hematoma, especially as intracranial pressure increases. However, it is not the earliest manifestation of a change in neurological status. Changes in heart rate may occur later in the progression of the condition.

Choice C rationale:

Widened pulse pressure can also occur in patients with a subdural hematoma due to increased intracranial pressure. However, it is not the earliest manifestation of a change in neurological status. Other neurological signs would likely appear before changes in pulse pressure are evident.

Choice D rationale:

Change in level of consciousness is the earliest manifestation of a change in neurological status with a subdural hematoma. As intracranial pressure increases, the brain's functioning can be affected, leading to alterations in consciousness, ranging from mild confusion to unconsciousness.

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Correct Answer is B

Explanation

Let's break down the calculation:

Given:

Patient weight: 154 lbs
Enoxaparin dosage: 0.75 mg/kg
Available enoxaparin: 60 mg/0.6 mL

Step 1: Convert pounds to kilograms:

1 lb is approximately 0.4536 kg
So, 154 lbs = 154 * 0.4536 kg/lb = 69.85 kg (approximately 70 kg)

Step 2: Calculate the total dose of enoxaparin:

Desired dose = 0.75 mg/kg * 70 kg = 52.5 mg

Step 3: Determine the volume to administer:

We have enoxaparin 60 mg/0.6 mL
To find the volume for 52.5 mg:
- (52.5 mg / 60 mg) * 0.6 mL = 0.525 mL
- Rounded to the nearest tenth, this is 0.5mL.

Therefore, the nurse should administer 0.5mL of enoxaparin

A. Use fingers to remove loose tissue. B. Open small blisters to expose air. C. Wash the burn with a mild soap. D. Apply wet-to-dry dressing.

Correct Answer is C

Explanation

Choice A rationale:

Using fingers to remove loose tissue is not an appropriate action for the nurse to take when providing hydrotherapy for a burn wound. This action can cause further trauma to the wound and increase the risk of infection.

Choice B rationale:

Opening small blisters to expose air is contraindicated in burn wound management. The blister roof provides a natural barrier against infection, and puncturing them increases the risk of infection and delays the healing process.

Choice C rationale:

The correct answer is to wash the burn with a mild soap. Cleaning the burn wound with mild soap and water helps remove debris and minimize the risk of infection without causing additional damage.

Choice D rationale:

Applying wet-to-dry dressings is an outdated and inappropriate practice for burn wound care. Wet-to-dry dressings can be painful, disrupt wound healing, and increase the risk of infection. Modern burn wound care focuses on maintaining a moist environment to support optimal healing.

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A nurse in an emergency department is providing care for a client who has a subdural hematoma. The nurse should identify that which of the following is the earliest manifestation of a change in neurological status?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer enoxaparin 0.75 mg/kg subcutaneously to a client who weighs 154 lb. The amount available is enoxaparin 60 mg/0.6 mL. How many mL should the nurse administer?(Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.).

Correct Answer is B

Explanation

A nurse is preparing to provide hydrotherapy for a client who has a burn wound. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse educator is teaching a newly licensed nurse about strategies to reduce the risk of infection in the client care area. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

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