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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A Reason: Sweating and pallor are early signs and symptoms of dumping syndrome, which is a condition where food moves too quickly from the stomach to the small intestine, causing rapid fluid shifts and hormonal changes. Sweating and pallor are caused by hypoglycemia, which occurs when the high concentration of food in the small intestine stimulates insulin secretion.

Choice B Reason: Abdominal cramping and pain are late signs and symptoms of dumping syndrome, which occur about one to three hours after eating. Abdominal cramping and pain are caused by intestinal distension, spasms, and gas formation.

Choice C Reason: Double vision and chest pain are not signs and symptoms of dumping syndrome, but may indicate other serious conditions, such as stroke or heart attack. Double vision and chest pain should be reported to the provider immediately.

Choice D Reason: Bradycardia and indigestion are not signs and symptoms of dumping syndrome, but may be related to other gastrointestinal disorders, such as gastritis or peptic ulcer disease. Bradycardia and indigestion should be evaluated by the provider for further diagnosis and treatment.

A. Clinical obesity defined by abnormally high BMI or waist circumference B. Elevated blood pressure C. High triglycerides D. Hypercholesterolemia E. Hyperglycemia

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

Explanation

Choice A Reason: This is correct because clinical obesity is a risk factor for metabolic syndrome. Clinical obesity is defined by having a body mass index (BMI) of 30 or higher, or a waist circumference of more than 40 inches for men or 35 inches for women. Obesity can increase insulin resistance and inflammation, which can lead to metabolic syndrome.

Choice B Reason: This is correct because elevated blood pressure is a risk factor for metabolic syndrome. Elevated blood pressure is defined by having a systolic blood pressure of 130 mm Hg or higher, or a diastolic blood pressure of 85 mm Hg or higher. High blood pressure can damage the blood vessels and increase the risk of cardiovascular disease, which is associated with metabolic syndrome.

Choice C Reason: This is correct because high triglycerides are a risk factor for metabolic syndrome. Triglycerides are a type of fat that circulates in the blood and provides energy for the cells. High triglycerides are defined by having a level of 150 mg/dL or higher. High triglycerides can increase the risk of fatty liver disease and pancreatitis, which are related to metabolic syndrome.

Choice D Reason: This is correct because hypercholesterolemia is a risk factor for metabolic syndrome. Hypercholesterolemia is defined by having a total cholesterol level of 200 mg/dL or higher, or a low-density lipoprotein (LDL) cholesterol level of 100 mg/dL or higher. LDL cholesterol is also known as "bad" cholesterol because it can build up in the arteries and cause plaque formation and narrowing, which can lead to cardiovascular disease and metabolic syndrome.

Choice E Reason: This is correct because hyperglycemia is a risk factor for metabolic syndrome. Hyperglycemia is defined by having a fasting blood glucose level of 100 mg/dL or higher, or a hemoglobin A1c level of 5.7% or higher. Hemoglobin A1c is a measure of average blood glucose over three months. Hyperglycemia can indicate impaired glucose metabolism and insulin resistance, which are hallmarks of metabolic syndrome.

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Naxlex Comprehensive Predictor Exams

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence?

Correct Answer is A

Explanation

A client asks the nurse to explain what metabolic syndrome is. Which of the following will the nurse include in education about risk factors for this syndrome? (Select all that apply.)

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

Explanation

A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? (Select all that apply.)

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.)

A nurse is preparing to review discharge instructions with a client who reports having hearing loss. Which of the following actions should the nurse plan to take?

A nurse caring for a client with hepatitis is providing education to the client about portal hypertension. Which of the following will the nurse include in the teaching?

A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?

A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify as a deep partial-thickness burn?

A nurse is reviewing the medical record of a client who is experiencing delirium. Which of the following in the health record should the nurse identify as a cause of this disorder?

When assessing a client diagnosed with basal cell carcinoma, which of the following findings will the nurse expect?