A nurse is collecting data from a client who fell at home and reported a brief loss of consciousness. Which of the following findings should the nurse immediately report to the charge nurse?

Edematous bruise on forehead

Client disoriented to place

Heart rate 110/min and regular

Small drops of clear ﬂuid in left ear

Answer and Explanation

The Correct Answer is D

The nurse should immediately report small drops of clear ﬂuid in the left ear to the charge nurse. This finding could indicate a cerebrospinal ﬂuid (CSF) leak, which can occur as a result of a head injury. A CSF leak can be a serious medical condition that requires immediate attention.

An edematous bruise on the forehead, client disorientation to place, and a heart rate of 110/min and regular are also important findings that the nurse should report to the charge nurse. However, these findings are not as urgent as the presence of small drops of clear ﬂuid in the left ear.

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Correct Answer is A

Explanation

a.A GCS score of 8 indicates severe impairment, suggesting the client may be in a state where they cannot perform basic self-care activities and thus require total nursing care.

b.A GCS score of 8 indicates severe impairment but not necessarily a deep coma. Scores below 8 suggest a comatose state, but deep coma is more likely to be indicated by a score of 3-4.

c.A GCS score of 8 is not consistent with a client who is alert and oriented. This score indicates significant neurological impairment.

d.A GCS score of 8 does not indicate stable neurological status. It suggests severe impairment and potentially unstable or deteriorating neurological condition.

A. Internal rotation B. Abduction C. Adduction D. External rotation

Correct Answer is B

Explanation

The nurse should place the client's right leg in abduction following a right total hip arthroplasty. Abduction means moving the leg away from the midline of the body. This position helps to prevent hip dislocation by keeping the hip joint in proper alignment.

Internal rotation, adduction, and external rotation are not appropriate positions for the client's right leg following a right total hip arthroplasty. Internal rotation means turning the leg inward towards the midline of the body. Adduction means moving the leg towards the midline of the body. External rotation means turning the leg outward away from the midline of the body. These positions can increase the risk of hip dislocation.

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A nurse is collecting data from a client who fell at home and reported a brief loss of consciousness. Which of the following findings should the nurse immediately report to the charge nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has a score of 8 using the Glasgow Coma Scale. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is caring for a client who is postoperative following a right total hip arthroplasty. In which of the following positions should the nurse place the client's right leg?

Correct Answer is B

Explanation

A nurse is contributing to the plan of care for a client to achieve the outcome of functional healing of a fracture. Which of the following nursing interventions is the highest priority to assist in meeting this outcome?

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