The emergency department nurse assesses a client with a head injury. The client lost consciousness at the time of the head injury and then regained consciousness but is now unconscious again.
Which condition does the nurse suspect?
Epidural hematoma.
Concussion.
Skull fracture.
Subdural hematoma.
The Correct Answer is A
Head injuries require rapid assessment of neurological changes to differentiate between various intracranial hemorrhages. This scenario applies knowledge of the classic lucid interval, which is a hallmark clinical presentation specifically associated with arterial bleeding in the intracranial space.
Choice A rationale
An epidural hematoma typically involves an arterial bleed, often the middle meningeal artery. The classic presentation is a brief loss of consciousness followed by a lucid interval before rapid neurologic deterioration as the hematoma expands quickly.
Choice B rationale
A concussion is a mild traumatic brain injury characterized by temporary neurological dysfunction without structural damage on imaging. While it involves a transient loss of consciousness, it does not typically present with the classic lucid interval followed by unconsciousness.
Choice C rationale
A skull fracture is a structural break in the cranial bones. While fractures can cause intracranial bleeding, the fracture itself is a skeletal injury and does not describe a specific pattern of alternating consciousness without associated hematoma formation.
Choice D rationale
Subdural hematomas involve venous bleeding between the dura and arachnoid membranes. They typically present with a more gradual decline in consciousness over days or weeks, rather than the rapid lucid interval characteristic of an arterial epidural bleed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Maintaining airway patency while managing intracranial pressure requires a balance between oxygenation and avoiding spikes in pressure. Knowledge of airway management and the physiological effects of hypoxia on cerebral edema is essential for prioritizing immediate life-saving interventions.
Choice A rationale
Elevating the head of the bed to 30 to 45 degrees promotes venous drainage and reduces intracranial pressure. While a standard nursing intervention for these patients, it does not clear an obstructed airway caused by pooled secretions.
Choice B rationale
Limiting stimulation helps prevent sudden increases in intracranial pressure caused by environmental stress. Although important for neurological stability, it is not the priority when the client's airway is compromised by secretions that prevent adequate ventilation.
Choice C rationale
Suctioning is necessary to clear the airway and maintain oxygenation. Hypoxia and hypercapnia are potent vasodilators that significantly increase intracranial pressure. Clearing the airway is the first priority, though it should be done quickly to minimize stimulation.
Choice D rationale
Sedatives may be used to reduce metabolic demand and blunt the intracranial pressure response to noxious stimuli like suctioning. However, administration takes time and does not physically remove the secretions causing the immediate airway obstruction..
Correct Answer is A
Explanation
Identifying life-threatening complications in immunocompromised patients is critical. Knowledge of the systemic inflammatory response syndrome and hemodynamic instability in neutropenic patients must be applied to differentiate between oncological emergencies like sepsis, tumor lysis syndrome, and superior vena cava obstruction.
Choice A rationale
Sepsis in neutropenic patients often leads to septic shock, characterized by hypotension (80/40 mm Hg) and tachycardia (142/min). The high fever and rapid breathing indicate a systemic response to infection and inadequate tissue perfusion.
Choice B rationale
Tumor lysis syndrome results from rapid cell destruction, causing hyperkalemia, hyperuricemia, and renal failure. While it is an oncological emergency, it does not typically present with the acute hemodynamic collapse and profound hypotension seen in this scenario.
Choice C rationale
While chemotherapy induces fatigue, it does not cause severe hypotension, high fever, or extreme tachycardia. These findings represent a critical physiological crisis rather than the expected side effects of exhaustion or malaise during oncological treatment.
Choice D rationale
Superior vena cava syndrome involves obstruction of blood flow from the upper body, causing facial edema, neck vein distention, and dyspnea. It does not primarily present with acute fever, sepsis symptoms, or profound hypotension.
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