A nurse is collecting data from a client who fell at home and reported a brief loss of consciousness. Which of the following findings should the nurse immediately report to the charge nurse?

Edematous bruise on forehead

Client disoriented to place

Heart rate 110/min and regular

Small drops of clear ﬂuid in left ear

Answer and Explanation

The Correct Answer is D

The nurse should immediately report small drops of clear ﬂuid in the left ear to the charge nurse. This finding could indicate a cerebrospinal ﬂuid (CSF) leak, which can occur as a result of a head injury. A CSF leak can be a serious medical condition that requires immediate attention.

An edematous bruise on the forehead, client disorientation to place, and a heart rate of 110/min and regular are also important findings that the nurse should report to the charge nurse. However, these findings are not as urgent as the presence of small drops of clear ﬂuid in the left 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

The nurse should place the client's right leg in abduction following a right total hip arthroplasty. Abduction means moving the leg away from the midline of the body. This position helps to prevent hip dislocation by keeping the hip joint in proper alignment.

Internal rotation, adduction, and external rotation are not appropriate positions for the client's right leg following a right total hip arthroplasty. Internal rotation means turning the leg inward towards the midline of the body. Adduction means moving the leg towards the midline of the body. External rotation means turning the leg outward away from the midline of the body. These positions can increase the risk of hip dislocation.

A. Peripheral edema B. Diarrhea C. Decreased pedal pulses D. Hypertension

Correct Answer is D

Explanation

A nurse collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm should monitor the client for hypertension as a manifestation of increased intracranial pressure. Increased intracranial pressure can cause changes in blood pressure, including hypertension.

a. Peripheral edema is not a manifestation of increased intracranial pressure. Peripheral edema is swelling in the extremities and can be caused by a variety of conditions.

b. Diarrhea is not a manifestation of increased intracranial pressure. Diarrhea is loose or watery stools and
can be caused by a variety of conditions.

c. Decreased pedal pulses are not a manifestation of increased intracranial pressure. Decreased pedal
pulses can indicate poor circulation to the feet and can be caused by a variety of conditions.

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 is collecting data from a client who fell at home and reported a brief loss of consciousness. Which of the following findings should the nurse immediately report to the charge nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following a right total hip arthroplasty. In which of the following positions should the nurse place the client's right leg?

Correct Answer is B

Explanation

A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Correct Answer is D

Explanation

A nurse is caring for a client who has a spinal cord injury. The nurse suspects that the client has autonomic dysreﬂexia. Which of the following actions should the nurse take first?

A nurse is collecting data from a client who has rheumatoid arthritis. Which of the following is an expected finding for this client?

A nurse is caring for a client who has been placed in halo traction to immobilize his cervical spine. Which of the following actions should the nurse take?

A nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is assisting in the planning of preventative care for a client who is restless following a traumatic brain injury with increased intracranial pressure. Which of the following is an appropriate nursing action?

A client returns to the surgical unit from the PACU in skeletal traction. The nurses should take action to correct. Which of the following problems with the traction setup?

A nurse enters a client's room and finds the client on the ﬂoor in the clonic phase of a tonic-clonic seizure. Which of the following interventions should the nurse take?

A nurse is collecting data from a client who fell at home and reported a brief loss of consciousness. Which of the following findings should the nurse immediately report to the charge nurse?