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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Your heart condition is caused by excessive stretching of the ventricles": Dilated cardiomyopathy (DCM) is characterized by the dilation or enlargement of the heart's chambers, particularly the ventricles. This dilation results in weakened myocardial contraction and impaired systolic function. The primary cause of DCM is often idiopathic (unknown), but it can also be secondary to various factors such as genetics, infections, toxins, or systemic diseases. The statement correctly identifies the pathophysiological basis of DCM as excessive stretching or dilation of the ventricles, leading to impaired cardiac function.
B. "Your heart condition is caused when the ventricular tissue becomes fibrous and fatty": This statement is incorrect. Fibrous and fatty changes in ventricular tissue are characteristic of another type of cardiomyopathy known as hypertrophic cardiomyopathy (HCM), not dilated cardiomyopathy (DCM). In DCM, the primary abnormality is dilation of the heart chambers rather than fibrous and fatty changes in the myocardium.
C. "Your heart condition is caused from stiffening of the walls of the ventricles": This statement describes restrictive cardiomyopathy (RCM), not dilated cardiomyopathy (DCM). In restrictive cardiomyopathy, the ventricular walls become stiff and rigid, impairing diastolic filling and ventricular relaxation. However, in DCM, the primary abnormality is dilation or enlargement of the ventricles rather than stiffening of the ventricular walls.
D. "Your heart condition is caused by thickening of the ventricular walls and septum": This statement describes hypertrophic cardiomyopathy (HCM), not dilated cardiomyopathy (DCM). In HCM, there is abnormal thickening of the ventricular walls and septum, leading to reduced chamber size and impaired diastolic filling. However, in DCM, the primary abnormality is dilation or enlargement of the ventricles rather than thickening of the ventricular walls.
Correct Answer is ["A","B","C","D","E"]
Explanation
A. Restlessness: Restlessness is a common behavioral manifestation in clients with Alzheimer's disease. It can be caused by various factors, including confusion, agitation, discomfort, or unmet needs. Restlessness may manifest as pacing, fidgeting, or difficulty sitting still.
B. Aggression: Aggression, including verbal or physical aggression, is a behavioral manifestation that can occur in clients with Alzheimer's disease. Aggression may result from frustration, confusion, fear, or other underlying factors. It can present challenges for both the individual with Alzheimer's and their caregivers.
C. Depression: Depression is a mood disorder that can occur in individuals with Alzheimer's disease. Symptoms of depression may include persistent sadness, feelings of hopelessness, social withdrawal, and loss of interest in previously enjoyed activities. Depression can exacerbate cognitive decline and functional impairment in individuals with Alzheimer's.
D. Hyperactivity: Hyperactivity, characterized by excessive or restless activity, can occur in some individuals with Alzheimer's disease. Hyperactivity may be a manifestation of agitation, anxiety, or other underlying factors. It can present challenges for caregivers and may require interventions to manage.
E. Lethargy: Lethargy, or extreme fatigue and lack of energy, can also occur in individuals with Alzheimer's disease. Lethargy may result from physical and cognitive decline, medication side effects, depression, or other medical conditions. It can contribute to decreased engagement in activities and worsening of cognitive function.
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