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 D

Explanation

Choice A Reason: Increasing protein from red meat is not part of client education, as it can worsen the condition and increase the risk of complications. Red meat is high in fat and low in fiber, which can cause constipation and increase the pressure in the colon. Diverticulosis is a condition where small pouches or sacs form in the wall of the colon due to weak spots or increased pressure.

Choice B Reason: Decreasing fluid intake is not part of client education, as it can worsen the condition and increase the risk of complications. Fluid intake should be increased to prevent dehydration and promote bowel movements. Diverticulosis can cause abdominal pain, bloating, cramping, and changes in bowel habits.

Choice C Reason: Incorporating soft foods that are pureed in consistency is not part of client education, as it can worsen the condition and increase the risk of complications. Soft foods are low in fiber and can cause constipation and increase the pressure in the colon. Diverticulosis can lead to diverticulitis, which is inflammation or infection of the pouches or sacs.

Choice D Reason: This is the correct choice. Increasing dietary fiber is part of client education, as it can improve the condition and prevent complications. Fiber helps soften the stool and reduce the pressure in the colon. Diverticulosis can be managed by eating a high-fiber diet, drinking plenty of fluids, exercising regularly, and avoiding straining or holding stools.

A. Avoid swimming underwater B. Wear earphones when in crowded places C. Keep eyes open during an acute attack D. Sit or lie down if whirling occurs E. We do not know the exact cause F. Damage to the ear from excess noise is the cause

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

Explanation

Choice A reason: This is correct because avoiding swimming underwater can help prevent the worsening of Meniere's disease. Meniere's disease is a disorder of the inner ear that causes episodes of vertigo, tinnitus, hearing loss, and fullness in the ear. Swimming underwater can increase pressure in the ear and trigger an attack. The nurse should advise the client to avoid activities that involve changes in altitude or pressure, such as flying, diving, or climbing.
Choice B reason: This is incorrect because wearing earphones when in crowded places can worsen Meniere's disease. Earphones can increase noise exposure and damage hearing, which is already impaired by Meniere's disease. The nurse should advise the client to avoid loud noises and use hearing aids if needed.
Choice C reason: This is incorrect because keeping eyes open during an acute attack can increase vertigo and nausea. Vertigo is a sensation of spinning or moving when still, which can be caused by Meniere's disease. Keeping eyes open can make vertigo worse by creating a visual mismatch with vestibular signals from the inner ear. The nurse should advise the client to close their eyes or focus on a stationary object during an attack.
Choice D reason: This is correct because sitting or lying down if whirling occurs can help prevent falls or injuries due to vertigo. Whirling is another term for vertigo, which can affect balance and coordination. Sitting or lying down can reduce movement and stabilize posture during an attack. The nurse should advise
the client to avoid driving or operating machinery when experiencing vertigo.
Choice E reason: This is correct because we do not know the exact cause of Meniere's disease. Meniere's disease is thought to be related to abnormal fluid balance or pressure in the inner ear, but what triggers this condition is unknown. The nurse should educate the client about possible risk factors, such as genetics, infections, allergies, autoimmune disorders, or head trauma, but also acknowledge the uncertainty and variability of the disease.
Choice F reason: This is incorrect because damage to the ear from excess noise is not the cause of Meniere's disease. Damage to the ear from excess noise can cause noise-induced hearing loss, which is a type of sensorineural hearing loss that affects the cochlea or the auditory nerve. Meniere's disease is a type of mixed hearing loss that affects both the cochlea and the middle ear. The nurse should not confuse or misinform the client about the cause of their condition.

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Naxlex Comprehensive Predictor Exams

A nurse is creating an education plan for a client who has diverticulosis. The nurse should plan to include which of the following in the client education?

Correct Answer is D

Explanation

A nurse is providing education to a client recently diagnosed with Meniere's disease. Which of the following will the nurse include in the teaching? (Select all that apply.)

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

Explanation

The nurse provides instructions to a client diagnosed with inflammatory bowel syndrome (IBS) about measures to treat diarrhea caused by acute flare-ups. Which statement by the client indicates a need for further teaching?

A client presents to the clinic with complaints of otalgia and muffled sounds. The client is diagnosed with external otitis. Which of the following will the nurse not include in client teaching?

A client receiving parenteral nutrition by central venous access reports feeling unwell. The nurse assesses the client and suspects that the central line has become infected. Which of the following findings indicate that the client has developed a systemic infection? Select all that apply.

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support?

A nurse is caring for a client who is postoperative from glaucoma surgery in the right eye. Which of the following will the nurse include in the postoperative education to the client? (Select all that apply.)

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?

A client diagnosed with cholecystitis reports right upper quadrant pain that radiates to the right shoulder. Which of the following interventions is the priority for the nurse to implement?