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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale: Her healthcare provider prescribing a calcium channel blocker for hypertension is not directly linked to lymphedema.

Choice B rationale: Sustaining an insect bite to her left arm yesterday - Trauma or injury, such as an insect bite, to the affected limb post-mastectomy can increase the risk of

lymphedema.

Choice C rationale: Losing twenty pounds since the surgery might influence overall health but doesn’t specifically relate to lymphedema.

Choice D rationale: Her hobby of playing classical music on the piano is unrelated to the risk of developing lymphedema.

A. A glycated hemoglobin (HbA1c) value of 6.9 B. A postprandial blood glucose level of 170 mg/dL. C. A confirmed fasting plasma glucose level of 100 mg/dL and a postprandial blood glucose level of 200 mg/dL D. A fasting plasma glucose level of 90 mg/dL

Correct Answer is C

Explanation

Choice A rationale: A glycated hemoglobin (HbA1c) value of 6.9 indicates that the client has prediabetes, which is a risk factor for developing diabetes.

Choice B rationale: A postprandial blood glucose level of 170 mg/dL is within the normal range.

Choice C rationale: This indicates that the client has diabetes mellitus. According to the American Diabetes Association, a diagnosis of diabetes can be made if one of the

following criteria is met: a fasting plasma glucose level of 126 mg/dL or higher, a postprandial blood glucose level of 200 mg/dL or higher, or an HbA1c value of 6.5% or higher.

Choice D rationale: A fasting plasma glucose level of 90 mg/dL is within the normal range.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse working in a postoperative surgical clinic is assessing a woman who had a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk for developing lymphedema?

Correct Answer is B

Explanation

The nurse reviews the laboratory reports of a client and concludes that the client has diabetes. Which finding helped the nurse to reach this conclusion?

Correct Answer is C

Explanation

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