A client admitted after a motor vehicle accident arrives with a Glasgow coma score (GCS) of 14 with a mild headache. 4 hours later, the client's GCS has decreased to 10, and now has a dilated pupil on the left side. Which of the following acute traumatic brain injuries does the nurse suspect the client has suffered?
Laceration
Acute subdural hematoma
Intracerebral hemorrhage
Epidural hematoma
The Correct Answer is D
Choice A reason: This is incorrect because laceration is not an acute traumatic brain injury, but a type of wound that involves tearing or cutting of the skin or other tissues. Laceration can occur as a result of a motor vehicle accident, but it does not cause changes in the GCS or pupil size. The nurse should assess the client's skin for any signs of laceration, such as bleeding, swelling, or infection.
Choice B reason: This is incorrect because acute subdural hematoma is not likely to cause a dilated pupil on the left side. Acute subdural hematoma is a type of traumatic brain injury that involves bleeding between the dura mater and the arachnoid mater, which are two layers of the meninges that cover the brain. An acute subdural hematoma can cause a rapid decrease in the GCS, but it usually causes a dilated pupil on the same side as the injury, not on the opposite side.
Choice C reason: This is incorrect because intracerebral hemorrhage is not likely to cause a dilated pupil on the left side. Intracerebral hemorrhage is a type of traumatic brain injury that involves bleeding within the brain tissue itself. Intracerebral hemorrhage can cause a gradual decrease in the GCS, but it usually causes neurological deficits that correspond to the location of the bleeding, such as weakness, numbness, or aphasia, not pupillary changes.
Choice D reason: This is correct because epidural hematoma can cause a dilated pupil on the left side. Epidural hematoma is a type of traumatic brain injury that involves bleeding between the dura mater and the skull. Epidural hematoma can cause a lucid interval, which is a period of normal consciousness followed by a sudden decrease in the GCS, and a dilated pupil on the opposite side of the injury, due to compression of the third cranial nerve. The nurse should notify the provider immediately and prepare for emergency surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because administering medications and electrolytes is not the primary purpose of inserting a nasogastric tube for a client with acute peritonitis. Medications and electrolytes can be given through other routes, such as IV or oral.
Choice B Reason: This is incorrect because dilating the stomach as a presurgical preparation is not a relevant Reason for inserting a nasogastric tube for a client with acute peritonitis. Dilating the stomach may be done before some types of gastric surgery, but it does not apply to peritonitis.
Choice C Reason: This is incorrect because stating that you will not be able to eat for several days is not an adequate explanation for inserting a nasogastric tube for a client with acute peritonitis. This statement does not address the rationale or the benefits of the procedure. It may also cause anxiety and resentment in the client.
Choice D Reason: This is the correct choice because removing secretions and decompressing the stomach is the main Reason for inserting a nasogastric tube for a client with acute peritonitis. Peritonitis is an inflammation of the peritoneum, the membrane that lines the abdominal cavity. It can cause abdominal distension, pain, nausea, and vomiting. A nasogastric tube can suction out the gastric contents and reduce the pressure and irritation in the abdomen.
Correct Answer is B
Explanation
Choice A reason: This is incorrect because allergies are not a risk factor for developing Barrett's esophagus. Allergies are hypersensitive reactions of the immune system to certain substances, such as pollen, dust, or food. They can cause symptoms such as sneezing, itching, or hives, but they do not affect the esophagus or stomach acid.
Choice B reason: This is the correct answer because gastroesophageal reflux disorder (GERD) is the most common risk factor for developing Barrett's esophagus. GERD is a condition where the lower esophageal sphincter (LES) does not close properly and allows stomach acid to flow back into the esophagus. This can cause inflammation, irritation, and damage to the esophageal lining. Over time, this can lead to changes in the cells of the esophagus, which is called Barrett's esophagus.
Choice C reason: This is incorrect because being a vegetarian is not a risk factor for developing Barrett's esophagus. Being a vegetarian means avoiding meat and animal products in the diet. This can have health benefits such as lower cholesterol and blood pressure levels, but it does not affect the esophagus or stomach acid.
Choice D reason: This is incorrect because Barrett's esophagus is not a genetic condition that one is born with. Barrett's esophagus is an acquired condition that results from chronic exposure to stomach acid in the esophagus. It is not inherited from one's parents or passed on to one's children.
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