A nurse in an emergency department is providing care for a client who has a subdural hematoma. The nurse should identify that which of the following is the earliest manifestation of a change in neurological status?
Severe headache.
Bradycardia.
Widened pulse pressure.
Change in level of consciousness.
The Correct Answer is D
Choice A rationale:
Severe headache can be a symptom of a subdural hematoma, but it is not the earliest manifestation of a change in neurological status. Other symptoms may appear before a severe headache, such as an altered level of consciousness.
Choice B rationale:
Bradycardia can occur with a subdural hematoma, especially as intracranial pressure increases. However, it is not the earliest manifestation of a change in neurological status. Changes in heart rate may occur later in the progression of the condition.
Choice C rationale:
Widened pulse pressure can also occur in patients with a subdural hematoma due to increased intracranial pressure. However, it is not the earliest manifestation of a change in neurological status. Other neurological signs would likely appear before changes in pulse pressure are evident.
Choice D rationale:
Change in level of consciousness is the earliest manifestation of a change in neurological status with a subdural hematoma. As intracranial pressure increases, the brain's functioning can be affected, leading to alterations in consciousness, ranging from mild confusion to unconsciousness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Taking sitz baths can provide comfort but will not directly address the transmission of herpes simplex virus type 2 (HSV-2). It is essential to avoid sexual activity during outbreaks to prevent spreading the infection to a partner.
Choice B rationale:
Cleansing lesions with 1/2 strength peroxide may irritate the affected area and delay healing. The recommended approach is to use gentle soap and water to clean the lesions.
Choice C rationale:
"I will avoid sexual activity until my lesions are healed.”. This statement indicates an understanding of the teaching because HSV-2 is highly contagious during active outbreaks. Avoiding sexual activity during this time is essential to prevent transmitting the virus to a partner.
Choice D rationale:
"I am not contagious once I begin antiviral medication.”. This statement is incorrect as antiviral medications can help manage outbreaks but do not eliminate the risk of transmission entirely. The virus remains contagious until lesions are completely healed.
Correct Answer is A
Explanation
Choice A rationale:
Applying clean gloves when removing the old dressing from the catheter site is essential to prevent infection and maintain an aseptic technique during peritoneal dialysis catheter care. Gloves protect both the nurse and the patient from potential contamination.
Choice B rationale:
Cleansing the area by using a circular motion beginning at the catheter site and moving outward is not the correct technique. When caring for a dialysis catheter, the nurse should cleanse the site using an outward, circular motion starting from the insertion site to minimize the risk of contamination.
Choice C rationale:
Using warm water to cleanse the catheter site is not recommended. The peritoneal dialysis catheter site should be cleaned with an appropriate antiseptic solution or disinfectant, as warm water alone may not effectively remove bacteria or prevent infections.
Choice D rationale:
Placing an occlusive dressing over the catheter site after cleaning is not the standard practice for peritoneal dialysis catheter care. Typically, a clean, dry dressing is applied to the catheter site after cleaning to keep it clean and dry, but it should not be occlusive.
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