What should the nurse do first when a client with a head injury begins to have clear drainage from the nose?

Compress the nares.

Administer decongestant for postnasal drip.

Tilt the head back.

Collect the drainage.

Answer and Explanation

The Correct Answer is D

Choice A Reason: Compressing the nares is not the first action that the nurse should take, as it may increase intracranial pressure and worsen the head injury.

Choice B Reason: Administering decongestant for postnasal drip is not the first action that the nurse should take, as it may mask the signs of cerebrospinal fluid (CSF) leakage and delay diagnosis and treatment.

Choice C Reason: Tilting the head back is not the first action that the nurse should take, as it may cause aspiration of CSF or blood and increase the risk of infection.

Choice D Reason: Collecting the drainage is the first action that the nurse should take, as it helps to identify if the drainage is CSF or nasal secretions, and to monitor the amount and characteristics of the drainage.

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Correct Answer is A

Explanation

Choice A Reason: Urine output 800 mL/hr is a sign of diabetes insipidus, as it indicates that the kidneys are producing large amounts of diluted urine due to the lack of antidiuretic hormone (ADH) or its action.

Choice B Reason: Blood glucose 198 mg/dL is not a sign of diabetes insipidus, but it may indicate diabetes mellitus or hyperglycemia.

Choice C Reason: Serum sodium 145 mEq/L is not a sign of diabetes insipidus, but it is within the normal range (135-145 mEq/L).

Choice D Reason: Urine specific gravity 1.028 is not a sign of diabetes insipidus, but it indicates concentrated urine due to dehydration or other causes.

A. N0 indicates presence of regional lymph node involvement. B. TIS indicates that a tumor has been resolved. C. T4 indicates a tumor at its smallest size. D. M1 indicates tumor metastasis to a single site.

Correct Answer is D

Explanation

Choice A Reason: N0 does not indicate presence of regional lymph node involvement, but absence of it. N1 to N3 indicate increasing degrees of regional lymph node involvement.

Choice B Reason: TIS does not indicate that a tumor has been resolved, but that it is in situ, meaning that it is confined to the original site and has not invaded deeper tissues.

Choice C Reason: T4 does not indicate a tumor at its smallest size, but at its largest size. T1 to T4 indicate increasing sizes or extents of the primary tumor.

Choice D Reason: M1 indicates tumor metastasis to a single site, meaning that the cancer has spread to another organ or distant lymph node. M0 indicates no distant metastasis.

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What should the nurse do first when a client with a head injury begins to have clear drainage from the nose?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing data for a client who has a head injury. Which of the following findings should indicate to the nurse that the client might have diabetes insipidus?

Correct Answer is A

Explanation

A nurse is reinforcing teaching about TNM staging with a client who has cancer. Which of the following information should the nurse include in the teaching?

Correct Answer is D

Explanation

A client has been diagnosed with hypothyroidism. What information should the nurse obtain when conducting a focused assessment? Select all that apply.

The nurse is caring for a client after a total thyroidectomy. The nurse's priority should be to:

I can help you with formatting and editing the text. Here are the edited texts: Text 1: A nurse reviewing the laboratory of a client who had a total thyroidectomy discovers that his calcium level is 7 mg/dL. Which of the following client findings should the nurse expect?

The nurse is completing a health assessment of a client suspected of hyperthyroidism. Which of the following clinical manifestations should the nurse expect?

A nurse is caring for a client with myasthenia gravis who is exhibiting signs of cholinergic crisis. Which medication does the nurse ensure is available to treat this crisis?

A nurse is assisting with the care of a client who is 1 day postoperative following a thyroidectomy and reports severe muscle spasms of the lower extremities. Which of the following actions should the nurse take?

A lumbar puncture is performed on a client with suspected bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse determines that the diagnosis is confirmed if which findings are noted?