An 82-year-old client who sustained a head injury in a motor vehicle crash while on warfarin therapy is admitted for observation. The nurse is providing teaching regarding the client's diagnosis of a subdural hematoma. Which of the following statements by the client indicates an understanding of teaching?

"I developed a hematoma because an artery burst in my brain when my head hit the windshield."

"I developed a bleed in my brain because my platelets were too high."

"I developed a hematoma because I take a blood thinner and my head hit the windshield."

"I developed a hematoma because my bleeding times were too low and I hit my head."

Answer and Explanation

The Correct Answer is C

A. A subdural hematoma is typically caused by venous bleeding, not arterial bleeding. An arterial rupture would more likely cause an epidural hematoma, which is not the case here.
B. High platelet counts are not commonly associated with the formation of subdural hematomas. Subdural hematomas are usually due to bleeding related to anticoagulant use or trauma.
C. Taking a blood thinner like warfarin increases the risk of bleeding and hematoma formation, particularly when combined with head trauma. This statement correctly links the anticoagulant therapy and head injury as contributing factors to the subdural hematoma.
D. Low bleeding times are not a cause of hematomas. In fact, elevated bleeding times due to anticoagulant therapy would increase the risk of bleeding, not low bleeding times.

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Correct Answer is B

Explanation

A. Chicken noodle soup is high in sodium, which can exacerbate fluid retention and worsen symptoms of Meniere disease. Clients with Meniere disease are typically advised to follow a low-sodium diet to help manage their symptoms.
B. Scrambled eggs are low in sodium and are an appropriate food choice for a client with Meniere disease. This option supports the dietary modifications needed to manage the condition effectively.
C. Baked ham is high in sodium, which is not suitable for a client with Meniere disease. High-sodium foods can lead to fluid retention, worsening vertigo and other symptoms associated with the disease.
D. Cheese pizza contains significant amounts of sodium, which can aggravate Meniere disease symptoms. Clients are advised to avoid high-sodium foods to manage their condition better.

A. Assess for sources of bleeding and provide pressure on wounds B. Limit contact with infected visitors and place in positive pressure isolation C. Administer antiemetics and assess nutrition and hydration status D. Monitor energy levels and begin energy-conserving techniques

Correct Answer is B

Explanation

A. Assessing for sources of bleeding is important in clients with neutropenia, but the highest priority is preventing infection, as the client’s absolute neutrophil count is zero, indicating an extremely high risk for infection.
B. Limiting contact with infected visitors and placing the client in positive pressure isolation is crucial for preventing infections. With a neutrophil count of zero, the client is highly immunocompromised and at a significant risk of infection, making this the highest priority action.
C. Administering antiemetics and assessing nutrition and hydration are important for managing symptoms, but they do not address the immediate risk of infection associated with severe neutropenia.
D. Monitoring energy levels and implementing energy-conserving techniques are important for overall care but do not address the urgent need to protect the client from infections due to their neutropenic status.

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Naxlex Comprehensive Predictor Exams

A client with Meniere disease is instructed to modify his diet. The nurse would explain that which item would be acceptable for the client to include?

Correct Answer is B

Explanation

A client with acute lymphocytic leukemia received induction chemotherapy. The client's absolute neutrophil count is zero, and the client is experiencing fatigue and mild nausea. Which nursing action is the highest priority?

Correct Answer is B

Explanation

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