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: Cri du chat syndrome involves a high-pitched cry in infants and other distinct physical and developmental features, but it doesn't present with the described symptoms.
Choice B rationale: Klinefelter syndrome, characterized by an extra X chromosome (XXY) in males, typically presents with small testicles, gynecomastia (enlarged breast tissues), sexual dysfunction, and altered body proportions, such as long legs and a shorter trunk, aligning with the client's symptoms.
Choice C rationale: Patau syndrome (Trisomy 13) manifests with severe developmental issues, facial abnormalities, and other physical malformations, but the described symptoms are not typically associated with this syndrome.
Choice D rationale: Turner syndrome involves females with a missing or partially missing X chromosome (45, X), resulting in specific physical features and medical problems not consistent with the described symptoms in a male client.

Correct Answer is C
Explanation
Choice A rationale: Clients with Graves' disease may have increased sensitivity to light due to ocular manifestations like photophobia, so keeping the room well-lit may can cause eye irritation.
Choice B rationale: Encouraging frequent ambulation and exercise may worsen the symptoms of hyperthyroidism, such as tachycardia, palpitations, and tremors.
Choice C rationale: This is because clients with Graves' disease have an increased
metabolic rate and may experience weight loss, muscle wasting, and fatigue. A high- calorie and high protein diet can help prevent these complications and provide adequate nutrition for the client.
Choice D rationale: Placing extra blankets over the client may increase the body temperature and cause heat intolerance, which is another common symptom of Graves' disease.
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