While reviewing the clinical history of a client with brain injury, the nurse finds that there is a periorbital ecchymosis, which is referred to as raccoon eyes. The client also has leakage of cerebrospinal fluid (CSF) from the nose. Which fracture should the nurse suspect in the client?

Depressed fracture

Basilar skull fracture

Linear fracture

Frontal fossa fracture

Answer and Explanation

The Correct Answer is B

Choice A rationale: Often results from direct trauma to the skull, but not typically associated with CSF leakage or raccoon eyes.

Choice B rationale: Basilar skull fractures, particularly involving the anterior or middle fossa, can lead to CSF leakage from the nose (rhinorrhea) and periorbital ecchymosis (raccoon eyes).

Choice C rationale: A simple fracture line without displacement, less likely to cause CSF leakage and raccoon eyes.

Choice D rationale: Less commonly associated with CSF leakage and periorbital ecchymosis compared to basilar skull fractures.

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Correct Answer is A

Explanation

Choice A rationale: An allergy to sulfa drugs is important as some diabetes medications, like sulfonylureas, contain components related to sulfa drugs, which could cause an allergic reaction in susceptible individuals.

Choice B rationale: Smoking cessation and lifestyle history are important but might not directly impact initial diabetes treatment options.

Choice C rationale: Numbness in the soles of the feet might indicate neuropathy, a common complication of diabetes, but is not directly related to the choice of initial treatment.

Choice D rationale: While obesity is a risk factor for Type 2 diabetes, it's less critical for immediate treatment decisions compared to drug allergies that could impact medication choices.

A. A/V fistula assessment B. Blood pressure C. Pulse D. Anuria E. Oxygen saturation F. Temperature G. Neurological assessment

Correct Answer is ["B","C","D","E"]

Explanation

Choice A rationale: A/V fistula assessment is not concerning because a positive bruit and thrill indicate adequate blood flow through the fistula. A dry dressing with scant amount of blood is expected after hemodialysis.

Choice B rationale: The client's low blood pressure could indicate hypotension, which can be critical, especially after hemodialysis. It may contribute to the client's reported dizziness and fatigue.

Choice C rationale: The client’s pulse is irregular which may indicate cardiac arrhythmia. Choice D rationale: Anuria, the absence of urine output, is a significant concern. It could indicate kidney dysfunction or inadequate clearance of waste products, which may have implications following hemodialysis.

Choice E rationale: Oxygen saturation at 92% is relatively low. While the client is alert and oriented, a low oxygen saturation level may indicate potential respiratory compromise or inadequate oxygenation.

Choice F rationale: Temperature is not concerning because it is within normal range.

Choice G rationale: Neurological assessment is not concerning because the client is alert and oriented. The dizziness is likely related to the hypotension and will resolve once the blood pressure is stabilized.

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While reviewing the clinical history of a client with brain injury, the nurse finds that there is a periorbital ecchymosis, which is referred to as raccoon eyes. The client also has leakage of cerebrospinal fluid (CSF) from the nose. Which fracture should the nurse suspect in the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is taking a history of a newly diagnosed Type 2 diabetic who is beginning treatment. Which subjective information is most important for the nurse to note?

Correct Answer is A

Explanation

The nurse is caring for a 67-year-old client in the medical-surgical unit following hemodialysis. The nurse reviews the nursing note, vital signs, assessment, and medical history Which clinical data is most concerning to the nurse? Select all that apply

Correct Answer is ["B","C","D","E"]

Explanation

Polystyrene sulfonate (Kayexalate) is used in renal failure to:

While performing the genital assessment of a male client, a nurse observes that the client has curvature of the penis. Which condition does the nurse suspect in the client?

When planning care for a client with right ureteral renal calculi, which of the following nursing diagnosis has the less priority of care while caring for this patient?

Which antidiabetic medication is a sulfonylurea?

Which of the following describes the correct procedure for testing for Kernig's sign?

The healthcare provider performs a paracentesis on a client with ascites and 3 liters of fluid are removed. Which assessment parameter is most critical for the nurse to monitor following the procedure?

Spironolactone (Aldactone) is prescribed for a client with chronic cirrhosis and ascites. The nurse should monitor the client for which of the following medication-related side effects?