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 D

Explanation

Choice A rationale: This is not relevant to the current condition of the patient and does not support a diagnosis of renal calculi.

Choice B rationale: This is a sign of upper gastrointestinal bleeding, which can have many causes such as peptic ulcer, gastritis or esophageal varices. It is not related to renal calculi or urinary tract problems.

Choice C rationale: Renal calculi usually causes pain which usually radiates anteriorly to the lower abdomen, groin, labia, testicles or the perineum depending on the location of the stone.

Choice D rationale: This is a sign of hematuria, which is blood in the urine caused by the passage of renal calculi (kidney stones) through the urinary tract. Hematuria can also cause the urine to appear dark or brown in color.

A. Altered level of consciousness B. The onset of symptoms is months to years C. Progressively worsens D. May be caused by fluid and electrolyte imbalances or infection E. May be caused by uncontrolled hypertension and diabetes F. May cause impairments in judgment G. Memory impairments

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

Explanation

Choice A rationale: Altered consciousness is a hallmark feature of delirium, where individuals may experience fluctuations in awareness.

Choice B rationale: Delirium typically has an acute onset rather than symptoms developing over months to years.

Choice C rationale: Delirium often has a fluctuating course, rather than a consistent progressive decline.

Choice D rationale: Delirium can result from various factors including fluid/electrolyte imbalances or infections.

Choice E rationale: While these conditions might contribute to cognitive impairments, they are not typically associated with delirium.

Choice F rationale: Delirium can affect judgment, but it's not a defining feature.

Choice G rationale: While memory impairments can be seen in delirium, they're often accompanied by altered consciousness and fluctuations in awareness.

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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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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A client arrives at the clinic with his daughter, reporting memory impairments: Exhibits Which of the following clinical feature are consistent with delirium? Select all that apply?

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

Explanation

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