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 A
Explanation
Choice A Reason: This is the correct choice because driving a motorcycle is a high-risk activity that can expose the client to head trauma, especially if they do not wear a helmet. Traumatic brain injury (TBI) is a condition where the brain is damaged by an external force, such as a collision, fall, or assault.
Choice B Reason: This is incorrect because having high blood pressure is not a direct risk factor for traumatic brain injury. High blood pressure can increase the risk of stroke, which is a condition where the brain is damaged by an internal cause, such as a blood clot or hemorrhage.
Choice C Reason: This is incorrect because smoking and having a family history of brain cancer are not risk factors for traumatic brain injury. Smoking and genetic factors can increase the risk of developing brain tumors, which are abnormal growths of cells in the brain.
Choice D Reason: This is incorrect because golfing and driving a golf cart are low-risk activities that do not pose a significant threat to the client's head. Golfing and driving a golf cart may cause minor injuries, such as sprains, strains, or bruises, but not traumatic brain injury.
Correct Answer is D
Explanation
Choice A Reason: Culture is not a diagnostic test that uses an ultraviolet light source, but a laboratory test that involves growing microorganisms from a sample of body fluid or tissue. Culture can help identify the type and sensitivity of the infection-causing agent.
Choice B Reason: KOH is not a diagnostic test that uses an ultraviolet light source, but a chemical test that involves applying potassium hydroxide to a sample of skin, hair, or nail. KOH can help diagnose fungal infections by dissolving the keratin and revealing the fungal elements under a microscope.
Choice C Reason: Diascopy is not a diagnostic test that uses an ultraviolet light source, but a physical test that involves applying pressure to a lesion with a glass slide or lens. Diascopy can help differentiate between blanchable and non-blanchable lesions, such as erythema or petechiae.
Choice D Reason: Wood's is a diagnostic test that uses an ultraviolet light source, also known as a Wood's lamp or black light. Wood's can help observe color changes to the skin that are not visible under normal light, such as fluorescence or hypopigmentation. Wood's can help diagnose conditions such as tinea capitis, vitiligo, or erythrasma.
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