A 21-year-old male was admitted to the emergency department following a high-speed motorcycle accident.
He was reported to be unconscious at the scene, but upon arrival he was awake and oriented with a Glasgow Coma Scale (GCS) of 15. Suddenly, he becomes unconscious and mental status deteriorates to a GCS of 8. The nurse anticipates which of the following injuries?

Subarachnoid hemorrhage.

Diffuse axonal injury.

Epidural hematoma.

Subdural hematoma.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Subarachnoid hemorrhage is less likely given the sudden decrease in consciousness. This type of injury typically results in severe headache or focal neurological deficits, not rapid mental decline.

Choice B rationale

Diffuse axonal injury usually presents with persistent unconsciousness rather than sudden deterioration. It results from widespread shearing forces and is less likely with the reported history.

Choice C rationale

Epidural hematoma often presents with a lucid interval followed by sudden neurological decline, as described in this case. Rapid accumulation of blood between the dura and skull can compress brain tissue.

Choice D rationale

Subdural hematoma tends to cause gradual neurological deterioration rather than a sudden decrease in Glasgow Coma Scale. This occurs due to slower venous bleeding. .

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Free Nursing Study Resources

Correct Answer is ["66.7"]

Explanation

Step 1 is (1600 mL ÷ 24 hours).

Answer is 66.7 mL/hr.

A. Decrease fluids to reduce intraocular pressure. B. Eye drops will be needed lifelong. C. Limit the amount of salt in the diet. D. Avoid activities that overuse the eyes.

Correct Answer is B

Explanation

Choice A rationale

Fluid intake does not directly impact intraocular pressure. Management of glaucoma focuses on medications like eye drops and surgical interventions rather than restricting fluid intake.

Choice B rationale

Glaucoma treatments, including eye drops, aim to manage intraocular pressure. These medications are required lifelong to prevent optic nerve damage and preserve vision.

Choice C rationale

Excess salt impacts systemic blood pressure but does not directly influence intraocular pressure. Glaucoma management targets ocular pressure, not dietary sodium reduction.

Choice D rationale

Avoiding eye overuse may reduce strain but does not address intraocular pressure. Effective glaucoma treatment relies on pharmacological or surgical measures rather than activity limitation.

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Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer 1600 mL of total parental nutrition (TPN) over 24 hours. The nurse should set the IV pump to deliver how many mL/hr?

Correct Answer is ["66.7"]

Explanation

The nurse is developing a teaching plan for the client with glaucoma.Which of the following instructions would the nurse include in the plan of care?

Correct Answer is B

Explanation

The nurse is caring for a patient with a spinal cord injury who has a flaccid or atonic bladder.The nurse would provide discharge education to the patient and family regarding which bladder management technique?

The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a patient with an acute head injury.Which actions should the nurse take to achieve this goal? (Select All that Apply.)

A nurse is assessing a client experiencing motor loss as the result of a left-sided stroke.Which clinical manifestations would the nurse document?

A client with homonymous hemianopsia resulting from a stroke has a disturbed sensory perception.An appropriate nursing intervention to help the client learn to compensate for this deficit during the rehabilitation period would be to:

The nurse is performing an admission assessment on a client with a diagnosis of detached retina.Which of the following is associated with this eye disorder?

The nurse is caring for a patient with an acute brain injury.Which of the following sets of vital signs would concern the nurse about increasing intracranial pressure (ICP)?

The nurse is caring for a client who has had a stroke and who has received tissue plasminogen activator (t-P