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 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.
Correct Answer is ["A"]
Explanation
A. "I should not drive while taking this new medication."
Carvedilol is a beta blocker commonly prescribed for conditions like cardiomyopathy. One of the potential side effects of beta blockers, including carvedilol, is dizziness or drowsiness. These effects can occur, particularly when starting the medication or when the dosage is increased. Therefore, it's crucial for patients to understand that they may experience these symptoms and should avoid activities that require alertness, such as driving or operating heavy machinery, until they are aware of how the medication affects them. This precaution helps ensure their safety and the safety of others on the road.
B. "This new medication may decrease my sex drive."
Sexual dysfunction, including decreased libido or erectile dysfunction, is a recognized side effect of beta blockers like carvedilol. These medications can affect the autonomic nervous system and interfere with normal sexual function in some individuals. It's essential for patients to be aware of this potential side effect and to discuss any concerns with their healthcare provider. Open communication about sexual health can help address any issues that arise and explore alternative treatment options if necessary.
C. "This medication can make me have mood swings."
While mood changes are possible side effects of some medications, including certain classes of antidepressants or corticosteroids, they are not typically associated with beta blockers like carvedilol. Beta blockers primarily affect the cardiovascular system by blocking the effects of adrenaline, leading to decreased heart rate and blood pressure. While some patients may experience fatigue or depression as a side effect of beta blockers, mood swings are not a common manifestation. Therefore, this statement does not accurately reflect the potential side effects of carvedilol.
D. "I may have frequent hiccups while taking this medication."
While gastrointestinal side effects such as nausea, vomiting, or diarrhea are possible with carvedilol, frequent hiccups are not a commonly reported side effect of this medication. Hiccups, though often benign, can occasionally be bothersome or indicative of an underlying issue. However, they are not typically associated with beta blockers like carvedilol. Therefore, this statement does not accurately reflect the potential side effects of the medication.
E. "I may have urinary incontinence while taking this medication."
Urinary incontinence is a potential side effect of beta blockers like carvedilol. These medications can affect bladder function by relaxing the smooth muscle of the bladder and urethra, leading to urinary retention or incontinence in some individuals. Patients should be aware of this possibility and discuss any urinary symptoms with their healthcare provider. Depending on the severity of the symptoms, adjustments to the medication regimen or additional treatments may be necessary to manage urinary incontinence effectively.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.