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
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
Choice A rationale
While a stiff neck can be a symptom of a cerebral aneurysm, it is not a definitive sign. A stiff neck is more commonly associated with conditions like meningitis.
Choice B rationale
Most cerebral aneurysms do not cause symptoms until they rupture or become very large. Therefore, a person with a cerebral aneurysm typically will have no symptoms.
Choice C rationale
Seizures can occur if a cerebral aneurysm ruptures and causes bleeding in the brain. However, seizures are not a common symptom of unruptured cerebral aneurysms.
Choice D rationale
Nausea and vomiting can occur if a cerebral aneurysm ruptures and causes a sudden increase in intracranial pressure. However, these are not typical symptoms of an unruptured cerebral aneurysm.
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