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 C
Explanation
Choice A rationale: These symptoms are more indicative of diabetic ketoacidosis, not hypoglycemia.
Choice B rationale: Symptoms of increased urination, thirst, and hunger are more associated with hyperglycemia, not hypoglycemia.
Choice C rationale: These are classic signs of hypoglycemia and should be described to the client for early recognition and intervention.
Choice D rationale: These symptoms can occur in hypoglycemia but are less specific compared to sweating, cold, trembling, and tachycardia.
Correct Answer is B
Explanation
Choice A rationale: This does not match the peak time of NPH insulin.
Choice B rationale: This does not match the peak time of NPH insulin.
Choice C rationale: This does not match the peak time of NPH insulin.
Choice D rationale: This is because NPH insulin is an intermediate-acting insulin that has an onset of action of 1 to 2 hours, a peak of 6 to 12 hours, and a duration of 18 to 24 hours. Therefore, if Albert is given NPH insulin at 0730, the peak effect will occur between 1330 and 1930, which means that his blood glucose level will be lowest during this time.
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