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 A
Explanation
Acute neurological deficits following a stroke increase the risk of secondary complications. Knowledge of cranial nerve involvement and protective reflexes is vital. The nurse must prioritize airway and respiratory safety within the critical 24 hour post ischemic event window.
Choice A rationale
Right sided weakness often includes the facial and pharyngeal muscles, impairing the gag reflex and swallowing. This increases the risk of food or secretions entering the lungs, leading to pneumonia or acute respiratory distress during recovery.
Choice B rationale
While urinary retention can occur after a stroke due to neurogenic bladder or immobility, it is not an immediate life threat. It requires monitoring and management but takes lower priority than ensuring the client maintains a patent airway.
Choice C rationale
Contractures are a long term complication of immobility and muscle spasticity following a stroke. While range of motion exercises are important for rehabilitation, they are not a priority during the first 24 hours of acute stabilization.
Choice D rationale
Depression is a common psychological consequence of the lifestyle changes and deficits caused by a stroke. However, psychological assessment occurs later in the care plan after the client is physiologically stable and out of danger.
Correct Answer is A
Explanation
Biliary obstruction prevents the flow of bile into the duodenum, leading to systemic accumulation of bile components. This scenario requires applying knowledge of hepatic and biliary biochemical markers to differentiate between hepatocellular damage and obstructive cholestatic patterns.
Choice A rationale
Biliary obstruction causes cholestasis. Total bilirubin (normal 0.3 to 1.0 mg/dL), alkaline phosphatase (normal 30 to 120 units/L), and GGT (normal 8 to 38 units/L) all rise because they are concentrated in the obstructed bile ducts.
Choice B rationale
In an obstructive process, alkaline phosphatase and GGT are typically significantly elevated alongside bilirubin. Normal levels of these enzymes would point toward a hemolytic cause of jaundice rather than a mechanical obstruction of the biliary tree.
Choice C rationale
Obstructive jaundice is characterized by the accumulation of bile pigments and enzymes in the blood. Low levels of these markers are inconsistent with the clinical presentation of jaundice, dark urine, and pruritus from bile salt deposition.
Choice D rationale
Amylase and glucose elevations are markers for pancreatic dysfunction or metabolic stress. While biliary stones can cause pancreatitis, low AST levels are unlikely in hepatobiliary disease, and these markers do not confirm a biliary obstruction..
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