A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider?

Edematous bruise on forehead

Glasgow Coma Scale (GCS) score of 14

Pupils are 4 mm and reactive to light

Small drops of clear drainage in the client’s ear

Answer and Explanation

The Correct Answer is D

Choice A reason: An edematous bruise on the forehead is expected after a head injury and, while concerning, is not the most urgent finding. It indicates localized trauma but does not necessarily suggest intracranial complications like cerebrospinal fluid leakage, which poses a greater risk of infection or brain injury.

Choice B reason: A Glasgow Coma Scale score of 14 indicates mild impairment (normal is 15), which is concerning but not the priority. Clear ear drainage suggesting cerebrospinal fluid leak is more urgent, as it indicates a potential skull fracture and risk of meningitis, requiring immediate reporting.

Choice C reason: Pupils that are 4 mm and reactive to light are normal and not immediately concerning. This finding suggests intact cranial nerve function. Clear ear drainage, potentially cerebrospinal fluid, is a more critical sign of skull fracture or brain injury, warranting urgent provider notification.

Choice D reason: Small drops of clear drainage in the ear are highly concerning, as they may indicate cerebrospinal fluid leakage from a basilar skull fracture post-head injury. This poses a risk of meningitis or brain infection, requiring immediate reporting to the provider for diagnostic imaging and intervention.

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Correct Answer is D

Explanation

Choice A reason: Right hemiparesis is not expected in a right hemispheric stroke, as this region controls the left side of the body. Right-sided weakness occurs with left hemispheric strokes. Right hemispheric strokes typically cause left hemiparesis, spatial deficits, or behavioral changes due to their role in non-dominant functions.

Choice B reason: Inability to speak the first language (aphasia) is associated with left hemispheric strokes, affecting language centers like Broca’s or Wernicke’s areas. Right hemispheric strokes typically impact spatial awareness, emotional regulation, or non-verbal functions, not primary language skills, making this an unlikely alteration in this client.

Choice C reason: Difficulty reading is more associated with left hemispheric strokes, which affect language processing and comprehension. Right hemispheric strokes typically cause spatial and perceptual deficits, such as neglect or visual field issues, rather than specific reading difficulties, which are tied to dominant hemisphere language functions.

Choice D reason: Behavioral changes are expected in right hemispheric strokes, as this region governs emotional regulation, impulse control, and spatial perception. Clients may exhibit impulsivity, neglect of the left side, or inappropriate emotional responses due to disrupted neural pathways in the non-dominant hemisphere, affecting behavior and awareness.

A. Gently restrain the client’s extremities B. Place the client on a BiPAP machine for oxygenation C. Place a pillow under the client’s head D. Insert a padded tongue blade into the client’s mouth

Correct Answer is C

Explanation

Choice A reason: Gently restraining extremities during a tonic-clonic seizure is unsafe, as it can cause injury or increase muscle strain. The clonic phase involves rhythmic jerking, and restraint may lead to fractures or soft tissue damage. Protecting the client by cushioning the head and ensuring safety is the priority.

Choice B reason: Placing a client on a BiPAP machine during a seizure is impractical and unsafe. The clonic phase involves uncontrolled movements, making BiPAP application impossible. Post-seizure, oxygenation may be needed, but during the seizure, protecting the client from injury, like head trauma, takes precedence.

Choice C reason: Placing a pillow under the client’s head during a tonic-clonic seizure protects against head injury from repetitive clonic movements against the floor. This action ensures safety by cushioning the head, reducing the risk of trauma or skull fracture, which is a priority during active seizure activity.

Choice D reason: Inserting a padded tongue blade is contraindicated during a seizure, as it risks injury to the mouth or airway obstruction. The jaw is often clenched in the clonic phase, and forcing objects into the mouth can cause dental damage or aspiration, making this an unsafe intervention.

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A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?

Correct Answer is D

Explanation

A nurse enters a client’s room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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