During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment for

Cerebrospinal fluid leakage from the ears and nose.

Presence of a neck injury.

Patency of airway

neurological status with the Glasgow coma scale

Answer and Explanation

The Correct Answer is C

A. Cerebrospinal fluid leakage is important to note but not the immediate priority.
B. Assessing for neck injury is crucial but airway management takes precedence to prevent life-threatening hypoxia.
C. Ensuring airway patency is the highest priority in trauma care to maintain oxygenation and ventilation, which are vital for survival.
D. Neurological assessment with the Glasgow Coma Scale is important but comes after securing airway, breathing, and circulation.

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Correct Answer is C

Explanation

A. Hyperthermia, increased thirst, and polyuria are not related to Cushing's Triad; these symptoms suggest other conditions such as diabetes insipidus.
B. Confusion, blurred vision, and dizziness are nonspecific symptoms and do not define Cushing’s Triad.
C. Cushing's Triad is a classic neurologic emergency that indicates increased intracranial pressure. It is characterized by the triad of bradycardia (slow heart rate), decreased or irregular respirations, and hypertension (high blood pressure). This response is the body’s attempt to maintain cerebral perfusion in the face of rising intracranial pressure.
D. Tachycardia, shallow respirations, and hypotension are not consistent with Cushing’s Triad.

A. Increased oxygen supply and improved cardiac function, which results in lower ejection fraction. B. Hypertrophy and remodeling in heart failure result in poor contractility and increased oxygen demand as the hypertrophic muscle become inefficient over time. C. Reduced workload on the heart and improved cardiac output, leading to resolution of heart failure. D. Sustained improved contractility and decreased oxygen demand

Correct Answer is B

Explanation

A. Hypertrophy increases oxygen demand but does not improve cardiac function; it typically worsens ejection fraction.
B. Hypertrophy and remodeling initially help compensate but over time lead to inefficient heart muscle with poor contractility and increased oxygen demand, contributing to worsening heart failure.
C. Hypertrophy and remodeling increase, not reduce, workload, and do not resolve heart failure.
D. Contractility often declines and oxygen demand increases, contrary to this statement.

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During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment for

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Naxlex Comprehensive Predictor Exams

What is Cushing's Triad?

Correct Answer is C

Explanation

What is the result of hypertrophy and remodeling in the context of heart failure

Correct Answer is B

Explanation

A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider?

What is the consequence of low cerebral perfusion pressure?

Which compensatory mechanism is involved in both chronic heart failure and decompensated heart failure, leading to fluid retention and edema?

A patient is experiencing increased afterload. How would this condition likely impact the heart structure over time?

Which of the following statements about furosemide and potassium is true?

A nurse is providing discharge instructions for a client who has congestive heart failure. Which of the following client statements indicates to the nurse that the teaching was effective?

An acute care nurse receives a shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?

During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment for