A nurse is caring for a patient in the intensive care unit who was admitted with severe head trauma and cerebral edema. The patient opens their eyes spontaneously, is oriented, and obeys commands.Which of the following findings indicate the patient is experiencing a decline in their condition?
Patient is confused
Patient mumbles inappropriate words
Eyes do not open to name
The Correct Answer is A
Choice A rationale
A patient in the intensive care unit who was admitted with severe head trauma and cerebral edema, who opens their eyes spontaneously, is oriented, and obeys commands, would be experiencing a decline in their condition if they become confused. Confusion can be a sign of worsening brain function, indicating that the brain is not receiving enough oxygen or is being affected by a buildup of toxins. This could be due to increased intracranial pressure, decreased blood flow to the brain, or further injury to the brain tissue.
Choice B rationale
Mumbling inappropriate words can also be a sign of a decline in a patient’s condition. However, it is less specific than confusion. It could be due to a variety of factors, including medication side effects, sleep deprivation, or mental health issues.
Choice C rationale
If a patient’s eyes do not open to their name, it could indicate a significant decline in their condition. However, this is a more severe symptom than confusion and may not be the first sign of a decline.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Bruising over the mastoid process, also known as Battle’s sign, is a classic clinical sign of a basilar skull fracture.
Choice B rationale
Pooling of blood and edema around the eyes, or ‘raccoon eyes’, is another sign of a basilar skull fracture.
Choice C rationale
The ability to recall how the injury occurred is not directly related to the presence of a basilar skull fracture. Memory loss or confusion could be symptoms of a traumatic brain injury, but they are not specific to a basilar skull fracture.
Choice D rationale
Chvostek’s sign is a clinical sign of hypocalcemia, not a basilar skull fracture
Correct Answer is C
Explanation
Choice A rationale
Smoking is a risk factor for many health conditions, including headaches. However, it is not a common precipitating factor in both tension-type and cluster headaches.
Choice B rationale
Depression can be associated with both tension-type and cluster headaches, but it is not a common precipitating factor for these types of headaches.
Choice C rationale
Stress is a common precipitating factor for both tension-type and cluster headaches. Both types of headaches can be triggered by psychological factors like stress.
Choice D rationale
Poor posture can contribute to tension-type headaches by causing muscle tension in the neck and shoulders. However, it is not a common precipitating factor for cluster headaches.
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