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 D
Explanation
Choice A rationale: Fluoxymesterone is a synthetic forms of testosterone that can worsen BPH by increasing the level of DHT.
Choice B rationale: Danazol is a synthetic forms of testosterone that can worsen BPH by increasing the level of DHT.
Choice C rationale: Methyltestosterone is a synthetic forms of testosterone that can worsen BPH by increasing the level of DHT.
Choice D rationale: Finasteride is a medication that inhibits the conversion of testosterone to dihydrotestosterone (DHT), which is a hormone that stimulates the growth of the prostate gland. By reducing the level of DHT, finasteride can shrink the enlarged prostate and improve urinary symptoms in men with benign prostatic hyperplasia (BPH). The other choices are not appropriate for BPH.
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Correct Answer is D
Explanation
Choice A rationale: Symptoms and findings described align more with an acute, severe condition rather than a chronic one.
Choice B rationale: While cholecystitis can present with similar symptoms, the radiation of pain to the back is more indicative of a different condition.
Choice C rationale: Cholelithiasis (gallstones) might cause abdominal pain but typically doesn’t lead to fever and hypotension.
Choice D rationale: Symptoms including severe abdominal pain, radiation to the back, fever, and hypotension suggest acute pancreatitis, a potentially serious condition requiring urgent medical attention.
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