A nurse in the emergency department is caring for a client who has an epidural hematoma following a motor-vehicle crash. Which of the following is an expected finding for this client?

Drainage of clear ﬂuid from the ears

Alternating periods of alertness and unconsciousness

Narrowing pulse pressure

Extensive bruising in the mastoid area

Answer and Explanation

The Correct Answer is B

Choice A: Drainage of clear ﬂuid from the ears is not an expected finding for a client who has an epidural hematoma, but rather a sign of a basilar skull fracture, which is a diﬀerent type of head injury. The clear ﬂuid is cerebrospinal ﬂuid (CSF), which leaks from the brain through the fractured skull.

Choice B: Alternating periods of alertness and unconsciousness is an expected finding for a client who has an epidural hematoma, because it indicates a rapid increase in intracranial pressure (ICP) due to bleeding between the dura mater and the skull. The client may have a brief loss of consciousness at the time of injury, followed by a lucid interval, and then a rapid deterioration of mental status.

Choice C: Narrowing pulse pressure is not an expected finding for a client who has an epidural hematoma, but rather a sign of increased ICP due to any cause. Pulse pressure is the diﬀerence between systolic and diastolic blood pressure. As ICP rises, it compresses the brainstem and causes bradycardia and hypertension, resulting in a decreased pulse pressure.

Choice D: Extensive bruising in the mastoid area is not an expected finding for a client who has an epidural hematoma, but rather a sign of a basilar skull fracture, which is a diﬀerent type of head injury. The bruising is also known as Batle's sign, and it occurs due to blood pooling behind the ear.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A Reason: This choice is incorrect because urinary hesitancy is not the priority finding for the nurse to address.

Urinary hesitancy is a difficulty or delay in starting or maintaining a urine stream. It may be caused by various factors such as prostate enlargement, urinary tract infection, medication side eﬀects, or psychological issues. It may cause discomfort, pain, or urinary retention, but it does not pose an immediate threat to the client's life.

ChoiceB Reason: This choice is correct because dysphagia is the priority finding for the nurse to address. Dysphagia is a difficulty or inability to swallow food or liquids. It may be caused by various factors such as stroke, Parkinson's disease, dementia, esophageal cancer, or oral infections. It may cause malnutrition, dehydration, aspiration, or choking, which can lead to serious complications such as pneumonia, sepsis, or death. Therefore, the nurse should assess the client's swallowing function and provide appropriate interventions such as modifying the diet texture, using thickening agents, or teaching swallowing techniques.

ChoiceC Reason: This choice is incorrect because swollen gums are not the priority finding for the nurse to address. Swollen gums are an inﬂammation or enlargement of the gingival tissue that surrounds the teeth. They may be caused by various factors such as poor oral hygiene, gum disease, vitamin deficiency, medication side eﬀects, or hormonal changes. They may cause bleeding, pain, or infection, but they do not pose an immediate threat to the client's life.

Choice D Reason: This choice is incorrect because pruritus is not the priority finding for the nurse to address. Pruritus is a sensation of itching that aﬀects the skin. It may be caused by various factors such as dry skin, allergies, eczema, psoriasis, liver disease, or kidney disease. It may cause discomfort, scratching, or skin damage, but it does not pose an immediate threat to the client's life.

A. 54 percent B. 36 percent C. 18 percent D. 9 percent

Correct Answer is A

Explanation

Choice A Reason: To calculate the total body surface area (TBSA) affected by burns using the Rule of Nines, the body is divided into sections, each representing a percentage of TBSA:

Front of one leg = 9%
Back of one leg = 9%
Front of one arm = 4.5%
Back of one arm = 4.5%

Now for the calculation:

Both legs (front and back):
- Front of both legs = 9% × 2 = 18%
- Back of both legs = 9% × 2 = 18%
- Total for both legs = 18% + 18% = 36%
Both arms (front and back):
- Front of both arms = 4.5% × 2 = 9%
- Back of both arms = 4.5% × 2 = 9%
- Total for both arms = 9% + 9% = 18%
Total TBSA:
- Legs (36%) + Arms (18%) = 54%

The nurse should document burns to 54% of the client's total body surface area (TBSA).

Choice B Reason:This choice is incorrect because it uses the original rule of nines for adults, not children. It also does not account for the depth and degree of the burns.

Choice C Reason: This choice is incorrect because it uses the original rule of nines for adults, not children. It also does not account for the depth and degree of the burns.

Choice D Reason: This choice is incorrect because it uses a random percentage that does not correspond to any rule or calculation.

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 in the emergency department is caring for a client who has an epidural hematoma following a motor-vehicle crash. Which of the following is an expected finding for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address?

Correct Answer is B

Explanation

A nurse in an emergency department is caring for an adult client who has burns on the front and back of both his legs and arms. Using the rule of nines, the nurse should document burns to which percentage of the client's total body surface area (TBSA)?

Correct Answer is A

Explanation

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?

A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect?

A nurse is caring for a client who had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?

A nurse is caring for a client who has acute kidney injury (AKI). Which of the following arterial blood gas values would the nurse expect this client to have?

A nurse is monitoring a client who was admited with a severe burn injury and is receiving IV ﬂuid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate ﬂuid replacement?

A nurse is preparing to administer blood to a client. The unit of blood on hand is type B, and the client has type AB blood. Which of the following actions should the nurse take?