A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further?
A scalp laceration oozing blood.
Dizziness, nausea, and transient confusion.
Headache rated "8" on a 0-10 scale.
Serosanguineous nasal drainage.
The Correct Answer is D
Choice A rationale: This is a possible sign of TBI but is not necessarily indicative of a life- threatening condition.
Choice B rationale: This is a possible sign of TBI but is not necessarily indicative of a life- threatening condition.
Choice C rationale: This is a possible sign of TBI but is not necessarily indicative of a life- threatening condition.
Choice D rationale: Serosanguineous nasal drainage (a mixture of blood and clear fluid) may suggest a basilar skull fracture, which is a fracture of the base of the skull that can damage vital structures such as the brainstem, cranial nerves, or major blood vessels. This can lead to serious complications such as meningitis, cerebrospinal fluid leak, or hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: The correct answer is 5 units/hour. To calculate the units of insulin per hour, we need to use the following formula: units of insulin per hour = (units of insulin in the bag / volume of the bag) x infusion rate
Plugging in the given values, we get:
units of insulin per hour = (50 / 100) x 10 units of insulin per hour = 0.5 x 10
units of insulin per hour = 5
Therefore, the client is receiving 5 units of insulin every hour.
Choice B rationale: This is incorrect because it assumes that the infusion rate is equal to the units of insulin per hour, which is not true.
Choice C rationale: This is incorrect because it multiplies the units of insulin in the bag by the infusion rate, which is too high.
Choice D rationale: This is incorrect because it adds the units of insulin in the bag and the infusion rate, which is also too high.
Correct Answer is D
Explanation
Choice A rationale: The combination treats gonorrhea and chlamydia but not trichomonas.
Choice B rationale: While important, this combination aims to treat multiple potential infections, not solely prevent reinfection.
Choice C rationale: The dual therapy doesn’t cover syphilis; it's specifically targeted for gonorrhea and chlamydia.
Choice D rationale: Azithromycin covers both gonorrhea and chlamydia, so the combination ensures coverage for both possible infections.
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