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 A
Explanation
Choice A rationale: candidiasis - The described symptoms of inflammation, cottage
cheese-like discharge, and vaginal/vulvar inflammation are indicative of a yeast infection or candidiasis.
Choice B rationale: Chlamydia - Chlamydia often presents with different symptoms such as discharge, but it's not typically associated with a cottage cheese-like appearance.
Choice C rationale: bacterial vaginosis - Bacterial vaginosis typically presents with a different type of discharge, often described as "fishy" smelling, rather than a cottage cheese appearance.
Choice D rationale: trichomoniasis - Symptoms of trichomoniasis usually include frothy, malodorous discharge, not consistent with the described cottage cheese-like discharge.
Correct Answer is A
Explanation
Choice A rationale: With type 2 diabetes, insulin secretion is decreased, and insulin resistance is increased. This means that the pancreas does not produce enough insulin, and the cells of the body do not respond well to the insulin that is available. Insulin is a hormone that helps the body use glucose (sugar) for energy. Without enough insulin or with insulin resistance, glucose builds up in the blood, leading to high blood sugar levels and various complications.
Choice B rationale: This statement describes Type 1 diabetes, where the immune system destroys insulin-producing cells.
Choice C rationale: This describes type 1 diabetes, not type 2 diabetes. People with type 2 diabetes may or may not need to take insulin, depending on how well they can control their blood sugar levels with diet, exercise, and oral medications.
Choice D rationale: This refers to pancreatitis, which is a condition where the pancreas becomes inflamed due to infection, injury, or alcohol abuse. Pancreatitis can cause
severe abdominal pain, nausea, vomiting, fever, and elevated levels of pancreatic enzymes in the blood.
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