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.

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

Explanation

Choice A Reason: This choice is incorrect because headache is not a common manifestation of ARF. Headache may be caused by various factors such as dehydration, stress, sinusitis, or migraine, but it does not indicate ARF.

Choice B Reason: This choice is correct because severe dyspnea is a common manifestation of ARF. Dyspnea is a difficulty or discomfort in breathing that aﬀects the oxygen delivery and carbon dioxide removal from the body. It may be caused by various factors such as lung disease, heart disease, anemia, or anxiety, but it indicates ARF when it is severe and persistent.

Choice C Reason: This choice is incorrect because nausea is not a common manifestation of ARF. Nausea is a sensation of uneasiness or discomfort in the stomach that may precede vomiting. It may be caused by various factors such as food poisoning, motion sickness, medication side eﬀects, or pregnancy, but it does not indicate ARF.

Choice D Reason: This choice is correct because hypotension is a common manifestation of ARF. Hypotension is a condition in which the blood pressure is lower than normal (less than 90/60 mm Hg). It may be caused by various factors such as dehydration, blood loss, sepsis, or shock, but it indicates ARF when it is due to reduced cardiac output or vasodilation from hypoxia.

Choice E Reason: This choice is correct because decreased level of consciousness is a common manifestation of ARF. Decreased level of consciousness is a condition in which the person has impaired awareness or responsiveness to stimuli. It may be caused by various factors such as brain injury, stroke, seizure, or drug overdose, but it indicates ARF when it is due to increased carbon dioxide levels (hypercapnia) or decreased oxygen levels (hypoxemia) in the brain.

A. Laboratory testing of serum potassium upon admission B. Bumetanide 1 mg IV bolus every 12 hr C. 0.9% normal saline IV at 50 mL/hr continuous D. Morphine sulfate 2 mg IV bolus every 2 hr PRN pain

Correct Answer is C

Explanation

Choice A Reason: This choice is incorrect because laboratory testing of serum potassium upon admission is an appropriate prescription for a client who has acute heart failure following MI. Serum potassium is an electrolyte that aﬀects the cardiac function and rhythm. A normal serum potassium range is 3.5 to 5 mEq/L, and an abnormal level can indicate hypokalemia or hyperkalemia, which can cause arrhythmias, muscle weakness, or paralysis. Therefore, monitoring serum potassium is important to detect and correct any electrolyte imbalance and prevent complications.

Choice B Reason: This choice is incorrect because bumetanide 1 mg IV bolus every 12 hr is an appropriate prescription for a client who has acute heart failure following MI. Bumetanide is a loop diuretic that helps to reduce ﬂuid retention and edema by increasing the urine output and sodium excretion. It may be used for clients who have heart failure, hypertension, or renal impairment, but it can cause hypokalemia, hypotension, or dehydration.

Therefore, administering bumetanide as prescribed can help to improve the cardiac output and reduce the preload and afterload.

Choice C Reason: This choice is correct because 0.9% normal saline IV at 50 mL/hr continuous is an inappropriate prescription for a client who has acute heart failure following MI. 0.9% normal saline is an isotonic solution that contains the same concentration of solutes as blood plasma. It may be used for clients who have ﬂuid loss, dehydration, or shock, but it can worsen ﬂuid overload and pulmonary edema in clients who have acute heart failure. Therefore, clarifying this prescription with the provider is necessary to prevent further deterioration of the client's condition.

Choice D Reason: This choice is incorrect because morphine sulfate 2 mg IV bolus every 2 hr PRN pain is an appropriate prescription for a client who has acute heart failure following MI. Morphine sulfate is an opioid analgesic that helps to relieve pain and anxiety by binding to the opioid receptors in the brain and spinal cord. It may be used for clients who have moderate to severe pain, dyspnea, or chest discomfort, but it can cause respiratory depression, hypotension, or nausea. Therefore, administering morphine sulfate as prescribed can help to reduce the oxygen demand and improve the cardiac function.

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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 is caring for a client who has acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.)

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

Explanation

A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification?

Correct Answer is C

Explanation

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