What condition does the nurse suspect when a patient involved in a motor vehicle accident arrives at the emergency department with ecchymosis behind the ears and bleeding from the ears?

Epidural hematoma.

Ischemic stroke.

Subarachnoid hemorrhage.

Basilar skull fracture.

Answer and Explanation

The Correct Answer is D

Choice A reason: An epidural hematoma is a type of traumatic brain injury where blood accumulates between the dura mater and the skull. While it can cause severe symptoms, including headache, loss of consciousness, and neurological deficits, it does not typically present with ecchymosis behind the ears (Battle's sign) or bleeding from the ears. These signs are more indicative of a basilar skull fracture.

Choice B reason: An ischemic stroke occurs when a blood clot blocks or narrows an artery leading to the brain, causing reduced blood flow and oxygen to the brain tissue. Symptoms of an ischemic stroke include sudden weakness, numbness, difficulty speaking, and vision problems. However, it does not cause ecchymosis behind the ears or bleeding from the ears, which are specific signs of a basilar skull fracture.

Choice C reason: A subarachnoid hemorrhage is bleeding into the space between the brain and the tissue covering the brain (subarachnoid space). It often presents with a sudden, severe headache, nausea, vomiting, and loss of consciousness. While it is a serious condition, it does not typically cause ecchymosis behind the ears or bleeding from the ears.

Choice D reason: A basilar skull fracture is

The correct answer. This type of fracture involves the base of the skull and can cause characteristic signs such as ecchymosis behind the ears (Battle's sign) and bleeding from the ears due to the proximity of the fracture to the auditory canal and other structures. These symptoms are key indicators of a basilar skull fracture and require immediate medical attention.

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Correct Answer is D

Explanation

Choice A reason: Hypokalemia, or low potassium levels, is not typically expected in clients with extensive burn injuries. In fact, during the acute phase of burn injury, hyperkalemia is more common due to the release of potassium from damaged cells and the impairment of kidney function.

Choice B reason: Metabolic alkalosis is not a common finding in clients with extensive burns. Instead, metabolic acidosis is more likely due to the increased production of lactic acid from tissue hypoxia and impaired perfusion. Burn injuries can lead to significant fluid and electrolyte shifts, but metabolic alkalosis is not the usual result.

Choice C reason: Low hemoglobin can occur in burn patients due to fluid shifts and the loss of red blood cells from the injury itself. However, it is not the most characteristic laboratory finding associated with extensive burns compared to hyperkalemia.

Choice D reason: Hyperkalemia is the expected laboratory result in clients with extensive burn injuries. Burns cause massive cell destruction, leading to the release of intracellular potassium into the bloodstream. Additionally, impaired kidney function in the acute phase can further contribute to elevated potassium levels, making hyperkalemia a common and critical concern in burn patients.

A. Explain ways to decrease paroxysmal nocturnal dyspnea. B. Discuss the effects of medications, ways to assess fluid balance, and positions for enhancing respirations. C. Teach stress management techniques. D. Provide a list of support systems in the community.

Correct Answer is B

Explanation

Choice A reason: Explaining ways to decrease paroxysmal nocturnal dyspnea is helpful for managing this specific symptom of heart failure, which involves difficulty breathing at night due to fluid accumulation in the lungs. While this can improve comfort, it doesn't provide a comprehensive approach to managing heart failure symptoms at home.

Choice B reason: Discussing the effects of medications, ways to assess fluid balance, and positions for enhancing respirations offers a comprehensive approach to managing heart failure symptoms at home. Understanding medication effects helps clients adhere to their treatment plan and manage side effects. Assessing fluid balance is crucial for detecting fluid overload early, a common issue in heart failure. Learning positions that enhance respirations can improve breathing and overall comfort.

Choice C reason: Teaching stress management techniques is beneficial for overall well-being and can indirectly improve heart health by reducing stress, which can exacerbate heart failure symptoms. However, it is not as directly related to managing the physical symptoms of heart failure as other interventions.

Choice D reason: Providing a list of support systems in the community is valuable for emotional and practical support, which can improve quality of life for clients with heart failure. However, it does not directly address the physical symptoms or management of heart failure at home.

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What condition does the nurse suspect when a patient involved in a motor vehicle accident arrives at the emergency department with ecchymosis behind the ears and bleeding from the ears?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect?

Correct Answer is D

Explanation

Which instruction would best reduce the symptoms of a client with heart failure and assure more comfort at home?

Correct Answer is B

Explanation

To prevent the most common serious complication of peritoneal dialysis, it is important for the nurse to:

What does the nurse expect the healthcare provider to prescribe when a post-kidney transplant client develops oliguria, elevated temperature of 37.8°C, increased blood pressure, and signs of fluid retention 12 days after the surgery?

What findings would the nurse expect when caring for a client who is experiencing spinal shock?

The nurse is instructing the client with chronic kidney disease (CKD) to maintain adequate nutritional intake. Which diet would be most appropriate?

The emergency department nurse can expect to see which assessment cues in the patient with acute pancreatitis? Select all that apply.

The nurse has completed an assessment on a client with heart failure and a decreased cardiac output with an ejection fraction of 30%. Which finding should receive the highest priority?