The company transported an unconscious construction worker, who fell off the roof of a two-story building, to the hospital. Which clinical finding would the nurse report immediately?
Breath sounds vesicular on the right middle lobe
Increased body temperature
Bilaterally reactive pupils
Bleeding from the ears
The Correct Answer is D
Traumatic brain injury from a high-altitude fall can result in a basilar skull fracture, involving the petrous portion of the temporal bone. This fracture allows the escape of cerebrospinal fluid or blood through the auditory canal, posing an immediate risk of meningitis and indicating significant intracranial pressure changes or structural brain damage.
Rationale:
A. Vesicular breath sounds represent normal, soft, low-pitched sounds heard over most of the lung parenchyma. This is an expected finding indicating adequate ventilation and absence of consolidated tissue. It would not require immediate reporting as it signifies a stable respiratory status in that lobe.
B. While a fever can occur due to hypothalamic injury or infection, it is usually not the most acute priority post-trauma. An isolated temperature increase is less life-threatening than active hemorrhage. Immediate reporting focuses on neurological or circulatory collapse following a significant mechanical fall.
C. Bilaterally reactive pupils indicate that the oculomotor nerve and brainstem pathways are currently intact and functioning. This is a reassuring clinical sign in an unconscious patient. It suggests there is no immediate unilateral compression causing pupillary dilation or a fixed, non-reactive state.
D. Otorrhea or bleeding from the external auditory canal following head trauma strongly suggests a basilar skull fracture. This is a critical finding that must be reported to prevent herniation. It indicates potential dural tearing and requires urgent neurosurgical evaluation to manage potential complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Spinal cord injury at high cervical levels causes respiratory failure, diaphragm paralysis, loss of phrenic nerve output, and inability to maintain spontaneous ventilation due to disruption of C3–C5 motor innervation controlling diaphragmatic contraction and breathing mechanics function.
Rationale:
A. C6-C7 injury typically preserves diaphragmatic function because phrenic nerve originates above this level. Patients may have upper limb weakness but maintain independent breathing. Mechanical ventilation would be unlikely solely from injury at this level. Diaphragm paralysis is not expected clinically here.
B. T4-T6 injury affects intercostal muscles and trunk stability but spares cervical phrenic nerve function. Diaphragm remains fully functional allowing spontaneous respiration. Ventilatory failure requiring mechanical support would not result from thoracic-level injury alone in this spinal segment range.
C. C3-C5 injury disrupts phrenic nerve origins responsible for diaphragm innervation. This results in complete diaphragm paralysis and loss of spontaneous breathing. Patients require mechanical ventilation despite being conscious and neurologically intact above injury level. This explains ventilator dependence accurately.
D. T1-T2 injury affects sympathetic pathways and upper thoracic structures. Diaphragm function remains intact due to preserved phrenic nerve activity. Respiratory drive is maintained despite possible autonomic instability. Mechanical ventilation requirement would not typically result from this injury level.
Correct Answer is C
Explanation
Breast Breast self-examination identifies suspicious breast pathology including malignancy indicators arising from ductal epithelial changes inflammatory invasion hormonal fluctuations lymphatic obstruction requiring systematic clinical correlation and diagnostic imaging follow-up evaluation assessment
Rationale:
A. Deviated nipple suggests underlying ductal distortion often associated with malignancy or fibrotic changes. This finding requires further diagnostic evaluation such as imaging. It is not benign. Therefore it does require follow-up and contradicts option stating no follow-up needed here
B. Peau d'orange edema reflects lymphatic obstruction from inflammatory breast carcinoma. Skin thickening and dimpling are serious red flags. This requires urgent oncologic assessment and imaging. It is not normal and always warrants follow-up evaluation immediately clinically required in care
C. Cyclic tenderness is hormonally mediated breast discomfort linked to luteal phase estrogen and progesterone fluctuations. It is benign bilateral predictable and resolves with menses. No diagnostic workup is required unless persistent or atypical symptoms occur clinically no follow-up needed here
D. Blood-tinged discharge is a concerning sign of possible intraductal carcinoma or papilloma. It requires immediate diagnostic evaluation including imaging and cytology. It is not physiologic and always warrants follow-up with healthcare provider for malignancy exclusion follow-up required clinically needed
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