Which of the following is not a sign of a basilar skull fracture?
Hyperglycemia
Raccoon eyes
Battle’s sign
Positive halo sign test result
The Correct Answer is A
Choice A reason: Hyperglycemia is not a sign of a basilar skull fracture. It may occur in critical illness due to stress responses or diabetes but is not directly linked to skull fractures. Basilar skull fractures cause physical signs like cerebrospinal fluid leakage or bruising, not metabolic disturbances like elevated blood sugar.
Choice B reason: Raccoon eyes, or periorbital ecchymosis, are a hallmark sign of a basilar skull fracture. Blood from fractured cranial bones pools around the eyes due to gravity, indicating trauma to the skull base. This results from vascular disruption and is a specific clinical finding in such injuries.
Choice C reason: Battle’s sign, or mastoid ecchymosis, is a classic sign of a basilar skull fracture. Blood tracks behind the ear due to fracture-related hemorrhage in the posterior cranial fossa. This physical sign is highly specific and results from bone disruption near the mastoid process.
Choice D reason: A positive halo sign test result indicates cerebrospinal fluid leakage, a common feature of basilar skull fractures. The clear fluid mixed with blood forms a halo-like ring on absorbent material, reflecting a breach in the dura mater, making it a specific diagnostic sign.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Acknowledging the client’s excitement avoids the request but doesn’t address boundaries. A clear, professional response about policy maintains trust and safety, making this less effective and incorrect.
Choice B reason: Giving a personal address violates professional boundaries and safety policies. Nurses must maintain privacy, and sharing personal information is inappropriate, making this incorrect and risky.
Choice C reason: A harsh refusal damages therapeutic rapport. While correct about policy, the tone is unprofessional and may alienate the client, making this less appropriate than a polite explanation.
Choice D reason: Politely declining due to hospital policy maintains professionalism and boundaries while appreciating the client’s intent. This fosters trust and adheres to ethical standards, making it the correct response.
Correct Answer is B
Explanation
Choice A reason: Controlled coughing increases intrathoracic pressure, worsening ICP by impeding cerebral venous return. This is contraindicated, making it incorrect compared to measures that reduce ICP like bed elevation.
Choice B reason: Elevating the head of the bed to 30 degrees promotes venous drainage, reducing ICP. This is a standard intervention for managing increased ICP, making it the correct action for the client.
Choice C reason: Encouraging 2000 mL fluid intake risks fluid overload, increasing ICP. Fluid restriction may be needed, making this incorrect for managing a client with elevated intracranial pressure.
Choice D reason: A brightly lit environment can increase agitation, potentially raising ICP. A calm, dim setting is preferred, making this incorrect compared to elevating the head to reduce pressure.
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