An adult male client is brought to the emergency department (ED) by ambulance following a motorcycle collision. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse?

Diminished bilateral breath sounds.

Nausea with projectile vomiting.

Rebound abdominal tenderness.

Rib pain with deep inspiration.

Answer and Explanation

The Correct Answer is A

Rationale:
A. Diminished bilateral breath sounds: Reduced or absent breath sounds may indicate life-threatening conditions such as pneumothorax, hemothorax, or airway compromise. In trauma, airway and breathing take priority over other assessments, and immediate intervention is critical to prevent hypoxia and respiratory failure.

B. Nausea with projectile vomiting: Projectile vomiting may indicate increased intracranial pressure after head trauma. While concerning, airway management and breathing take precedence in emergency care. Vomiting is urgent but secondary to potential respiratory compromise.

C. Rebound abdominal tenderness: This suggests possible intra-abdominal injury, such as bleeding or organ damage. While requiring prompt evaluation, it is not immediately life-threatening compared with compromised ventilation or oxygenation.

D. Rib pain with deep inspiration: Rib pain indicates musculoskeletal injury, possibly with minor trauma to underlying organs. Pain management and monitoring are important, but it does not require immediate intervention in the presence of normal breathing and oxygenation.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["B","C","D"]

Explanation

Rationale:
A. Assess the client's understanding of the new medications: While medication reconciliation is important later, you cannot assess the "understanding" of a client who is currently in an acute state of confusion and hallucinating. The immediate focus must be on safety and stabilization.

B. Notify the charge nurse of the client's disorientation: Alerting the charge nurse ensures appropriate support, timely assessment, and coordination of care. Early communication is important for patient safety and rapid intervention if the client’s behavior escalates.

C. Document the client's hallucinations: Accurate documentation of observed behaviors and hallucinations provides critical information for the healthcare provider to assess potential causes, including adverse drug reactions, infection, or delirium. Documentation is essential for safe and effective care planning.

D. Reorient the client to time and space: Providing verbal reassurance and cues about the environment helps reduce anxiety, supports cognitive orientation, and may decrease agitation. Nonpharmacologic interventions are first-line strategies for managing acute confusion in older adults.

E. Restrain the client in her room using soft restraints: Physical restraints should be a last resort due to the risk of injury, increased agitation, and ethical considerations. Restraints are not indicated prior to attempting assessment, reorientation, and nonpharmacologic safety measures.

A. Send wound drainage for culture and sensitivity. B. Explain the purpose of a low bacteria diet. C. Use standard precautions and wear a mask. D. Institute contact precautions for staff and visitors. E. Monitor the client's white blood cell count (WBC).

Correct Answer is ["A","D","E"]

Explanation

Rationale:
A. Send wound drainage for culture and sensitivity: Obtaining a culture identifies MRSA as the causative organism and determines antibiotic susceptibility. This guides targeted antimicrobial therapy and reduces the risk of treatment failure. Accurate identification is essential for infection control and clinical management.

B. Explain the purpose of a low bacteria diet: A low bacteria (neutropenic) diet is reserved for clients with severe immunosuppression, such as those undergoing chemotherapy. Localized MRSA wound infections do not require dietary bacterial restriction. Nutrition should focus on adequate protein and calories for wound healing.

C. Use standard precautions and wear a mask: MRSA wound infections require standard precautions plus contact precautions. A mask is not routinely required unless there is risk of splashing or respiratory involvement. Gloves and gowns are the primary protective measures.

D. Institute contact precautions for staff and visitors: MRSA is transmitted via direct and indirect contact with contaminated surfaces or drainage. Contact precautions, including gloves and gowns, reduce transmission to healthcare workers and other clients. These precautions are essential in preventing hospital-acquired spread.

E. Monitor the client's white blood cell count (WBC): The WBC count helps assess the presence and progression of infection and the client’s response to treatment. Trends in WBC levels can indicate worsening infection or resolution. Ongoing monitoring supports timely clinical decision-making.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

An adult male client is brought to the emergency department (ED) by ambulance following a motorcycle collision. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C","D"]

Explanation

A client with foul smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention(s) should the nurse include in the plan of care (POC)? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

A young female adult wanders into the Emergency Department. She is disheveled and confused and states, "My date must have put something in my drink. He took my car, and I think he raped me. I don't exactly remember, but I know he hurt me." How should the nurse respond?

The nurse completes percussion of the abdomen on an older adult client. Which finding is considered normal for this client?

An older adult client is being discharged after implantation of a permanent pacemaker. The client should be instructed to avoid which item?

The nurse is caring for a client admitted with a spontaneous pneumothorax. Which action should the nurse include in this client's plan of care (POC)?

A client arrives to the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?

Patient Data The nurse is considering the care of plan. Which intervention(s) should be a part of the client's plan of care? Select all that apply.

The nurse reviews the information from the initial assessment and history and physical. Which 6 findings in the client's history should the nurse recognize as risk factors for a cerebrovascular event?