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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because the laboratory values are not within the expected reference range in a client who has DIC. DIC is a condition that causes abnormal activation of the clotting cascade, leading to widespread microthrombi formation and consumption of clotting factors and platelets. This results in bleeding complications and organ dysfunction.
Choice B Reason: This is correct because the laboratory values are prolonged in a client who has DIC. PT, aPTT, and INR are tests that measure the time it takes for blood to clot. PT measures the extrinsic pathway, aPTT measures the intrinsic pathway, and INR is a standardized ratio of PT. In DIC, these tests are prolonged because of the depletion of clotting factors and platelets.
Choice C Reason: This is incorrect because the laboratory values are not the same as the previous test values in a client who has DIC. DIC is an acute and dynamic condition that can change rapidly depending on the underlying cause and treatment. The laboratory values may fluctuate between normal, prolonged, or shortened depending on the balance between clotting and bleeding.
Choice D Reason: This is incorrect because the laboratory values are not decreased in a client who has DIC. Decreased laboratory values would indicate a shortened clotting time, which can occur in some cases of DIC when there is excessive clotting and thrombosis. However, this is not the typical finding in DIC, as most clients present with bleeding manifestations and prolonged clotting time.
Correct Answer is C
Explanation
Choice A: Contacting the provider for further orders is not necessary, because the client has type AB blood, which is compatible with any other blood type. The client can receive type B blood without any adverse reactions.
Choice B: Notifying the blood bank of the discrepancy is not required, because there is no discrepancy. The blood bank sent the correct type of blood for the client, according to their blood type.
Choice C: Administering the blood as ordered is the correct action, because type B blood is compatible with type AB blood. The client will not have any transfusion reactions or complications from receiving this type of blood.
Choice D: Completing an incident report is not appropriate, because there is no incident. The nurse did not make any error or mistake in administering the blood to the client. There is no need to document or report anything unusual.
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