A nurse is caring for a client 4 hours following surgical repair of a penetrating brain injury. Which of the following assessments should be the nurse's priority?

Pain level assessment.

Wound site assessment.

Neurological assessment.

Respiratory status assessment.

Answer and Explanation

The Correct Answer is C

A. While pain level assessment is important, it is not the priority immediately after a significant brain injury where neurological changes may occur.
B. Wound site assessment is also essential but does not take precedence over neurological assessment in this context.
C. A neurological assessment is the priority to identify any changes in the client's condition that may indicate complications such as increased intracranial pressure, which can occur after brain surgery.
D. Respiratory status assessment is important but is usually addressed through monitoring and interventions related to neurological function, as brain injuries can affect respiratory drive and function.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Mastoiditis often results in inflammation and infection that extend to the middle ear, causing the tympanic membrane to appear red, dull, thickened, and immobile upon examination.
B. A transparent and clear tympanic membrane is typical in a healthy ear, not in cases of mastoiditis.
C. A pearly colored tympanic membrane is also indicative of a normal, healthy ear without infection.
D. A pink-colored tympanic membrane may suggest mild irritation but is not a characteristic finding of mastoiditis.

A. Weight gain B. Hyperpigmentation C. Elevated blood pressure D. Purple striations

Correct Answer is B

Explanation

A. Weight gain is not typical in Addison's disease; instead, weight loss is common.
B. Hyperpigmentation, particularly in sun-exposed areas and skin folds, is a classic symptom of Addison's disease due to elevated ACTH levels.
C. Low blood pressure, not elevated, is common due to decreased cortisol levels.
D. Purple striations are more commonly seen in Cushing's syndrome rather than Addison's disease.

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A nurse is caring for a client 4 hours following surgical repair of a penetrating brain injury. Which of the following assessments should be the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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