The nurse is caring for a trauma patient with a suspected brain injury and Battle's Sign.
The nurse notices a yellow stain around fluid dripping from the patient's ear.
The nurse's priority intervention will be as follows:

Prevent the drainage by applying a pressure dressing.

Allow fluid to drain from the patient's ear onto gauze and notify the provider.

Hang intravenous (IV) fluids to replace fluids lost.

Administer antibiotics due to increased risk of infection.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Applying pressure to prevent drainage could force cerebrospinal fluid (CSF) back into the cranial cavity, increasing infection risk and intracranial pressure, potentially worsening brain injury. CSF leakage requires non-obstructive handling.

Choice B rationale

Allowing fluid to drain onto gauze prevents build-up of intracranial pressure while assessing for halo sign, indicating CSF leakage. Yellow staining reflects glucose presence in CSF, confirming dura mater damage.

Choice C rationale

Intravenous fluids manage hypovolemia but are not prioritized for trauma patient brain injuries. Replacing lost CSF requires specific medical intervention rather than fluid volume adjustments alone.

Choice D rationale

Antibiotics treat infections but are not first priority for confirmed CSF leakage, which demands careful monitoring of drainage to prevent neurological damage. Post-intervention antibiotics may be necessary.

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Correct Answer is C

Explanation

Choice A rationale

Childhood memory recall reflects cognitive functioning but is unrelated to the patient's rehabilitation involvement, which focuses on regaining lost functional capacities following injury. Such a goal lacks immediate functional relevance.

Choice B rationale

Returning to work as a corporate attorney may be an eventual aim but depends on higher cognitive recovery levels and is too specific. Early rehabilitation outcomes focus on participation in the recovery process.

Choice C rationale

Active participation indicates readiness and willingness to engage in therapies essential for regaining lost functions. It aligns with goals for a transition from acute care to rehabilitation emphasizing functional improvement.

Choice D rationale

Motor coordination improvements require therapy timelines extending beyond two weeks. Such a rigid short-term goal undermines individualized rehabilitation focusing on measurable progress over more realistic durations.

A. Is in the latent period of the disease. B. Continues to remain in HIV positive status. C. Has acquired immunodeficiency syndrome (AIDS). D. Has seroconverted.

Correct Answer is C

Explanation

Choice A rationale

The latent period of HIV includes asymptomatic phases when the CD4+ count remains above 200 cells/mm. Pneumocystic pneumonia and low CD4+ counts signify progression beyond latent HIV.

Choice B rationale

HIV-positive status reflects infection presence, but it does not confirm AIDS unless CD4+ count drops below 200 cells/mm and opportunistic infections occur, such as pneumocystic pneumonia.

Choice C rationale

AIDS is diagnosed when CD4+ count decreases below 200 cells/mm, coupled with opportunistic infections. Pneumocystic pneumonia indicates a weakened immune system due to advanced disease.

Choice D rationale

Seroconversion marks the initial immune response to HIV infection with detectable antibodies but occurs before CD4+ counts decline significantly and opportunistic infections appear.

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The nurse is caring for a trauma patient with a suspected brain injury and Battle's Sign.The nurse notices a yellow stain around fluid dripping from the patient's ear.The nurse's priority intervention will be as follows:

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who had a serious head injury.The patient has recovered enough to be transferred to a rehabilitation facility.Which of the following rehabilitation goals would be most appropriate for the patient?

Correct Answer is C

Explanation

A client, who has tested positive for human immunodeficiency virus (HIV), now presents with a CD4+ count of less than 200 cells/mm and pneumocystic pneumonia.A normal range for a CD4+ count is 500-1500 cells/mm.How would the nurse evaluate these findings? The client:

Correct Answer is C

Explanation

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The nurse is caring for a trauma patient with a suspected brain injury and Battle's Sign.
The nurse notices a yellow stain around fluid dripping from the patient's ear.
The nurse's priority intervention will be as follows: