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: Cloudy efluent doesn't necessarily indicate a need for emergency surgery unless accompanied by severe symptoms.

Choice B rationale: Cloudy efluent may indicate infection, so obtaining a culture and sensitivity test is crucial for appropriate treatment.

Choice C rationale: This step might be necessary if the efluent suggests infection, but sending a specimen for testing is the immediate priority.

Choice D rationale: This action isn't the first step; investigating the cause of cloudiness through testing is essential.

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

When providing care for a client receiving peritoneal dialysis. While draining the dialysate the nurse notices that the efluent is cloudy. Which intervention is most important for the nurse to carry out at this moment?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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