A nurse receives a report on a client with a basilar skull fracture. What findings should the nurse expect with this client?

Bruising over the mastoid process

Pooling of blood and edema around the eyes

Ability to recall how the injury occurred

Chvostek’s sign

Answer and Explanation

The Correct Answer is A

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

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Correct Answer is D

Explanation

Choice A rationale
Providing nonpharmacological pain interventions to each client equally is an example of justice, not autonomy. Justice in healthcare refers to treating all patients fairly and equitably.
Choice B rationale
Fulfilling a promise to a client that they will return with their pain medication is an example of fidelity, not autonomy. Fidelity refers to being faithful to commitments and promises.
Choice C rationale
Administering a scheduled pain medication for a client who is having pain is an example of beneficence, not autonomy. Beneficence refers to taking actions that are of benefit to the patient.
Choice D rationale
Giving a client the choice of when to take a pain medication is an example of autonomy. Autonomy in healthcare refers to the patient’s right to make decisions about their own care.

A. Client’s age B. History of sickle cell disease C. Parent who has cardiovascular disease D. Hypertension

Correct Answer is D

Explanation

Choice A rationale
Age is a non-modifiable risk factor for stroke. As people age, their risk of stroke increases. However, this is not something that can be changed or controlled.
Choice B rationale
Sickle cell disease is a genetic disorder that can increase the risk of stroke, particularly in children. However, it is not a modifiable risk factor because it is determined by the person’s genes.
Choice C rationale
Having a parent with cardiovascular disease can increase a person’s risk of stroke. However, this is a non-modifiable risk factor because it is determined by genetics.
Choice D rationale
Hypertension, or high blood pressure, is a major modifiable risk factor for stroke. It can be controlled through lifestyle changes and medication.

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A nurse receives a report on a client with a basilar skull fracture. What findings should the nurse expect with this client?

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Naxlex Comprehensive Predictor Exams

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