A nurse has received report on a client who has a basilar skull fracture. Which of the following findings should the nurse anticipate with this client?

Pooling of blood and edema around the eyes

Ability to recall how the injury occurred

Bruising over the mastoid process

Chvostek’s sign

Answer and Explanation

The Correct Answer is A

A. Pooling of blood and edema around the eyes: Basilar skull fractures can lead to leakage of cerebrospinal fluid (CSF) into the surrounding tissues, resulting in periorbital ecchymosis, also known as raccoon eyes, due to pooling of blood and edema around the eyes. This finding is characteristic of basilar skull fractures and is caused by disruption of the meninges and subsequent CSF leakage into the soft tissues of the face.

B. Ability to recall how the injury occurred: Memory loss regarding the events surrounding the injury, known as post-traumatic amnesia, is common with basilar skull fractures. This amnesia occurs due to the impact of the injury on the brain and may involve retrograde amnesia (loss of memory of events leading up to the injury) and anterograde amnesia (loss of memory of events occurring after the injury).

C. Bruising over the mastoid process: Bruising over the mastoid process, known as Battle sign, is associated with basilar skull fractures. Battle sign results from blood accumulation (hematoma) in the mastoid region behind the ear due to fracture-related injury to the middle meningeal artery or other blood vessels. This finding typically develops 24-48 hours after the injury.

D. Chvostek’s sign: Chvostek's sign is a clinical manifestation of hypocalcemia, not basilar skull fractures. It is elicited by tapping the facial nerve (facial nerve spasm) and is indicative of neuromuscular irritability due to decreased calcium levels. Chvostek's sign is not directly related to basilar skull fractures.

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Correct Answer is D

Explanation

A. White blood cell level of 5,900 mm3: While abnormal white blood cell levels can indicate infection or inflammation, they are not typically associated with directly contributing to an episode of delirium. However, underlying conditions that cause abnormal white blood cell levels, such as infection or inflammation, may contribute to delirium.

B. Potassium level of 4.1 mEq/L: Potassium imbalances can lead to various neurological symptoms, including weakness, paralysis, and cardiac arrhythmias. However, a potassium level of 4.1 mEq/L is within the normal range and is unlikely to directly contribute to an episode of delirium.

C. Hemoglobin level of 14.2 g/dL: Hemoglobin levels reflect the oxygen-carrying capacity of the blood and are not directly associated with delirium. While severe anemia or hypoxia can cause neurological symptoms, a hemoglobin level of 14.2 g/dL is within the normal range and is unlikely to directly contribute to delirium.

D. Blood glucose level of 254 mg/dL: Elevated blood glucose levels, as indicated by a blood glucose level of 254 mg/dL, can contribute to an episode of delirium. Hyperglycemia can lead to alterations in cerebral metabolism, neuronal dysfunction, and impaired cognitive function, predisposing individuals to delirium. Additionally, hyperglycemia can exacerbate preexisting neurological conditions and increase the risk of developing delirium in critically ill patients. Therefore, monitoring and managing blood glucose levels are essential in preventing and managing delirium in hospitalized patients.

A. Diminished hair growth on the lower extremities B. Loss of pigmentation over the shin area C. Shiny appearance to the lower extremities D. Swollen and enlarged veins

Correct Answer is D

Explanation

A. Diminished hair growth on the lower extremities: Diminished hair growth on the lower extremities is not typically a manifestation of peripheral venous disease. Instead, it may suggest poor circulation or arterial insufficiency.

B. Loss of pigmentation over the shin area: Loss of pigmentation over the shin area can occur in conditions such as chronic venous insufficiency, which is a form of peripheral venous disease. However, it is not the most characteristic manifestation.

C. Shiny appearance to the lower extremities: A shiny appearance to the lower extremities is often associated with arterial insufficiency rather than peripheral venous disease. It can indicate thinning of the skin due to poor circulation and oxygenation.

D. Swollen and enlarged veins: Swollen and enlarged veins, also known as varicose veins, are classic manifestations of peripheral venous disease. These veins result from venous insufficiency, which leads to blood pooling and increased pressure in the veins, causing them to dilate and become visibly enlarged.

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A nurse has received report on a client who has a basilar skull fracture. Which of the following findings should the nurse anticipate with this client?

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