A new client has been received into the emergency department following a pedestrian-automobile collision. The triage nurse recognizes which of the following as an emergency and correctly notifies the provider immediately?
Clear, watery drainage from the ear.
Enlarged post-auricular lymph nodes.
Odorless, brown cerumen in the ear.
White spots on the tympanic membrane.
The Correct Answer is A
Choice A reason: Clear, watery ear drainage post-collision suggests cerebrospinal fluid (CSF) leak from a skull fracture. This urgent finding risks infection or brain injury, warranting immediate provider notification for imaging and intervention in this trauma case accurately.
Choice B reason: Enlarged post-auricular nodes may indicate infection, not an acute emergency. Post-trauma, this is less critical than potential CSF leak, making it a lower priority for immediate provider action in this collision scenario fully here.
Choice C reason: Odorless, brown cerumen is normal earwax, not an emergency. After a collision, this benign finding doesn’t signal trauma-related urgency, excluding it from requiring prompt provider notification compared to more severe signs entirely here.
Choice D reason: White tympanic membrane spots suggest scarring or infection, not immediate danger. Post-collision, this lacks the acuity of CSF leak, rendering it non-emergent and less urgent for provider attention in this context comprehensively here.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: PSA isn’t highly reliable alone; false positives occur. It’s a screening tool, not definitive, requiring biopsy for diagnosis, making this inaccurate and less informative than explaining its broader causes for this client fully here.
Choice B reason: PSA complements, not replaces, digital rectal exam (DRE). Both detect cancer; PSA misses some tumors DRE finds, rendering this false and incomplete for teaching screening essentials to a committed client entirely here fully.
Choice C reason: Annual PSA at 25 is too early; guidelines suggest 50, or 40-45 with family history. This overstates frequency and timing, misguiding the client on evidence-based screening practices for prostate cancer risk comprehensively here.
Choice D reason: PSA rises with cancer, BPH, or infection, educating the client on its non-specificity. This accurate teaching supports informed screening with family history, clarifying why follow-up is key, making it the best response accurately here.
Correct Answer is D
Explanation
Choice A reason: Impaired judgment suggests frontal lobe pathology, like dementia, not normal aging. Age-related changes slow processing, not executive function, making this a disease sign, not a typical neurological shift in an 81-year-old fully here.
Choice B reason: Loss of remote memory indicates Alzheimer’s, not normal aging. Aging may slow recall, but long-term memory typically persists, excluding this as an expected age-related change in this neurological assessment entirely and accurately here.
Choice C reason: Intention tremors signal cerebellar disease, like Parkinson’s, not aging. Normal aging may reduce fine motor speed, but not cause action tremors, distinguishing this as pathological, not a standard age-related finding fully here.
Choice D reason: Reduced distal sensation, from nerve conduction slowing, is a common age-related change. Aging thins myelin, impairing peripheral nerves, making this the expected finding in an 81-year-old’s neurological exam accurately and comprehensively here.
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