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 A

Explanation

Choice A rationale: These lab findings, particularly concentrated urine (high specific gravity) and hyponatremia, are consistent with SIADH, where excessive ADH secretion leads to water retention and dilutional hyponatremia.

Choice B rationale: While it can affect sodium levels, Cushing's syndrome typically results in hypernatremia or normal sodium levels rather than hyponatremia.

Choice C rationale: Usually presents with hyponatremia but not specifically with high urine specific gravity or hematocrit.

Choice D rationale: DI is associated with high serum sodium and low urine specific gravity due to excessive excretion of dilute urine.

A. Fracture/immobilized the extremity B. Contracture / obtain a prescription for acetaminophen C. Sprain/ raise the leg D. Dislocation/apply heat to the area

Correct Answer is A

Explanation

Choice A rationale: Considering the mechanism of injury, pain severity, tenderness, swelling, and ecchymosis, there is a high suspicion of a fracture. Immobilization is essential to prevent further injury and reduce pain.

Choice B rationale: Contracture is less likely in this acute injury scenario. Acetaminophen might manage pain, but it doesn't address the risk factor.

Choice C rationale: A sprain is less likely given the severity of pain and the mechanism of injury. Raising the leg doesn't address the risk of a suspected fracture.

Choice D rationale: Dislocation doesn't align with the reported symptoms. Applying heat could potentially worsen inflammation.

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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?

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