The nurse is caring for a patient with a new traumatic brain injury and completes a neurologic assessment. The magnetic resonance imaging identifies an intracranial epidural hematoma. The nurse would immediately notify the provider of which assessment finding?

Eyes are deviated to the right.

Amnesia to the cause of the trauma.

Complaint of mild headache.

Pupils constrict from 5 mm to 2 mm with direct light stimulus.

Answer and Explanation

The Correct Answer is A

Choice A reason: Eyes are deviated to the right is an assessment finding that indicates increased intracranial pressure and possible herniation of the brain. It is a sign of cranial nerve III palsy, which affects the movement of the eye and the size of the pupil. It is a medical emergency that requires immediate intervention.

Choice B reason: Amnesia to the cause of the trauma is an assessment finding that indicates memory loss and possible concussion. It is a sign of damage to the temporal lobe, which is involved in memory formation and retrieval. It is not a medical emergency, but it requires further evaluation and monitoring.

Choice C reason: Complaint of mild headache is an assessment finding that indicates pain and discomfort. It is a common symptom of traumatic brain injury, but it is not specific or severe. It can be managed with analgesics and rest.

Choice D reason: Pupils constrict from 5 mm to 2 mm with direct light stimulus is an assessment finding that indicates normal pupillary response. It is a sign of intact cranial nerve II and III function, which control the vision and the pupil size. It is not a cause for concern or notification.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Relaxing in a hot bath before bedtime is not the best suggestion to help decrease fatigue for a patient with multiple sclerosis. Heat can worsen the symptoms of multiple sclerosis, such as muscle weakness, numbness, and vision problems. Therefore, the patient should avoid hot baths, showers, or saunas, and use cool compresses or fans to lower their body temperature.

Choice B reason: Performing deep breathing exercises every two hours is not the best suggestion to help decrease fatigue for a patient with multiple sclerosis. Deep breathing can help reduce stress and anxiety, but it does not address the underlying causes of fatigue, such as inflammation, nerve damage, or sleep problems. Therefore, the patient should consult their doctor for appropriate treatment options and medication adjustments.

Choice C reason: Scheduling short periods of rest throughout the day is the best suggestion to help decrease fatigue for a patient with multiple sclerosis. Fatigue is a common and disabling symptom of multiple sclerosis, which can affect the patient's daily activities and quality of life. Therefore, the patient should plan their tasks according to their energy level, prioritize the most important ones, and take frequent breaks to conserve their energy and prevent exhaustion.

Choice D reason: Including daily multivitamins in your diet is not the best suggestion to help decrease fatigue for a patient with multiple sclerosis. Multivitamins can provide some nutritional benefits, but they are not a substitute for a balanced and healthy diet. Therefore, the patient should eat a variety of foods, such as fruits, vegetables, whole grains, lean proteins, and low-fat dairy, and avoid processed, fried, or sugary foods that can increase inflammation and fatigue.

A. Apples, oranges and strawberries B. Tuna fish, white bread and green vegetables C. Lean beef, raisins and prunes D. White chicken meat, whole milk and rice

Correct Answer is C

Explanation

Choice A reason: This is incorrect. Apples, oranges and strawberries are good sources of vitamin C, which can help with iron absorption, but they are not high in iron content themselves. The patient should eat foods that are rich in both iron and vitamin C.

Choice B reason: This is incorrect. Tuna fish, white bread and green vegetables are not high in iron content either. Tuna fish is a source of protein, but it has less iron than other types of meat or fish. White bread is refined and has less iron than whole grain bread. Green vegetables have some iron, but not enough to meet the daily requirements.

Choice C reason: This is correct. Lean beef, raisins and prunes are high in iron content and can help the patient with iron deficiency anemia. Lean beef is a source of heme iron, which is more easily absorbed by the body than non-heme iron from plant sources. Raisins and prunes are dried fruits that have more iron than fresh fruits.

Choice D reason: This is incorrect. White chicken meat, whole milk and rice are not high in iron content either. White chicken meat has less iron than dark chicken meat or red meat. Whole milk is a source of calcium, which can interfere with iron absorption. Rice is a source of carbohydrates, but it has less iron than other grains or legumes.

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

The nurse is caring for a patient with a new traumatic brain injury and completes a neurologic assessment. The magnetic resonance imaging identifies an intracranial epidural hematoma. The nurse would immediately notify the provider of which assessment finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The home health nurse visits a patient with multiple sclerosis who complains of severe fatigue. Select the nurse's best suggestion to help decrease their symptom of fatigue.

Correct Answer is C

Explanation

The nurse provides education to a patient diagnosed with iron deficiency anemia. The nurse would teach the patient to eat which foods that are high in iron content?

Correct Answer is C

Explanation

An older adult is admitted to the hospital following a closed head injury from a fall that resulted in a 5-minute period of unconsciousness. Which priority nursing assessment indicates neurological deterioration in the patient?

Which early symptoms in a focused assessment by the nurse may indicate the presence of a brain tumor?

The nurse is caring for a patient with a head injury after a fall from a ladder. The nurse must evaluate the patient for which signs and symptoms of increased intracranial pressure?

The nurse assesses a patient with a recent spinal cord injury at the level of thoracic 5 vertebrae. The patient's blood pressure is 184/95 mm Hg, has a flushed face and blurred vision. What priority action would the nurse complete first?

The nurse is providing education to a young female recently diagnosed with multiple sclerosis. Select the common symptoms the nurse should include in the education plan that the patient should report to their health care provider. (Select all that apply)

A patient has a folic acid deficiency associated with not consuming food with folic acid. The nurse would expect a complete blood cell count (CBC) to reveal?

The nurse is educating the family about anticipated changes during the late stages of amyotrophic lateral sclerosis (ALS) for their father. What teaching point is most important for the nurse to include?

The emergency room nurse notes clear drainage dripping from the nose of a newly admitted patient with a head injury after diving into shallow water. Which initial intervention should the nurse perform?