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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E"]

Explanation

A. Administer pain medication as needed. Rationale: Pain management is essential for clients with traumatic brain injury (TBI) to ensure their comfort and to prevent agitation or increased intracranial pressure (ICP) due to pain. Administering pain medication as needed helps alleviate discomfort and promotes rest, which supports the client's recovery.

B. Maintain ventriculostomy at the correct position. Rationale: Ventriculostomy, also known as an external ventricular drain (EVD), is a critical component of managing intracranial pressure (ICP) in clients with traumatic brain injury. Maintaining the ventriculostomy at the correct position ensures accurate monitoring and drainage of cerebrospinal fluid (CSF), which helps control ICP levels and prevents complications such as cerebral edema.

C. Maintain the neck in the midline position. Rationale: Keeping the neck in a midline position is essential for clients with traumatic brain injury to prevent further injury to the cervical spine. Proper alignment of the neck helps maintain spinal stability and reduces the risk of exacerbating any existing spinal cord injury, which may coexist with the traumatic brain injury.

D. Elevate the head of the bed to 30 degrees. Rationale: Elevating the head of the bed to 30 degrees is recommended for clients with traumatic brain injury to promote cerebral venous drainage and reduce intracranial pressure (ICP). This position helps optimize cerebral perfusion and minimizes the risk of cerebral edema, which can occur with increased ICP.

E. Maintain enteral feedings. Rationale: Nutritional support is crucial for clients with traumatic brain injury to support healing and recovery. Enteral feedings, such as tube feedings, may be necessary if the client is unable to consume adequate nutrition orally due to impaired swallowing or altered consciousness. Providing enteral feedings ensures the client receives essential nutrients to support tissue repair and prevent malnutrition-related complications during the recovery process.

A. "You can have 2 to 3 cups of coffee throughout the day." B. "You should practice deep breathing exercises:' C. "You can use at least 2,300 mg of sodium daily." D. "You should avoid exercising."

Correct Answer is B

Explanation

A. "You can have 2 to 3 cups of coffee throughout the day": Caffeine consumption can exacerbate tinnitus symptoms in some individuals. Therefore, advising the client to limit caffeine intake, rather than specifying a quantity, would be more appropriate.

B. "You should practice deep breathing exercises": Deep breathing exercises and relaxation techniques can help reduce stress and anxiety, which may contribute to tinnitus symptoms. Stress management strategies can be beneficial in managing tinnitus-related distress.

C. "You can use at least 2,300 mg of sodium daily": High sodium intake may exacerbate tinnitus symptoms in some individuals. Advising the client to limit sodium intake would be more appropriate to potentially alleviate symptoms.

D. "You should avoid exercising": Regular exercise is generally beneficial for overall health and well-being, including stress reduction, which can help manage tinnitus symptoms. Therefore, advising the client to avoid exercising is not appropriate.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a traumatic brain injury (TBI). Which of the following nursing interventions should be added to the plan of care? (Select All that Apply.)

Correct Answer is ["A","B","C","D","E"]

Explanation

A nurse is instructing a client who is experiencing episodes of tinnitus on lifestyle modifications to make. Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is assessing a client who has peripheral venous disease. Which of the following findings should the nurse recognize as a manifestation of peripheral venous disease?

A nurse is educating the family of a client who has Alzheimer's disease. The nurse should be sure to communicate that which of the following behavioral manifestations can occur in clients with Alzheimer’s disease? (Select All that Apply.)

The spouse of an older client experiencing delirium is at the client's bedside. The nurse is providing an update to the spouse regarding the client's plan of care. Which of the following responses by the spouse indicates a need for further teaching?

A nurse is providing discharge education to a client who has valvular heart disease and peripheral vascular disease. Which of the following should the nurse include in the teaching about valvular heart disease?

A nurse is providing care for a postoperative client. Which of the following manifestations should the nurse identify as indicating the development of postoperative shock?

A nurse is assessing a client who is recovering from subarachnoid hemorrhage following a fall. Which of the following medications should the nurse understand is a potential reason for the fall? (Select All that Apply.)

A nurse is providing teaching to a group of clients about the changes that occur when clients experience cataracts. Which of the following statements should the nurse include in the teaching?

A nurse is providing teaching to a client who has coronary artery disease. Which of the following statements should the nurse include in the teaching to explain the correlation between changes in the coronary arteries and manifestations that occur?