The nurse is caring for a trauma patient with a suspected brain injury and Battle's Sign.
The nurse notices a yellow stain around fluid dripping from the patient's ear.
The nurse's priority intervention will be as follows:

Prevent the drainage by applying a pressure dressing.

Allow fluid to drain from the patient's ear onto gauze and notify the provider.

Hang intravenous (IV) fluids to replace fluids lost.

Administer antibiotics due to increased risk of infection.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Applying pressure to prevent drainage could force cerebrospinal fluid (CSF) back into the cranial cavity, increasing infection risk and intracranial pressure, potentially worsening brain injury. CSF leakage requires non-obstructive handling.

Choice B rationale

Allowing fluid to drain onto gauze prevents build-up of intracranial pressure while assessing for halo sign, indicating CSF leakage. Yellow staining reflects glucose presence in CSF, confirming dura mater damage.

Choice C rationale

Intravenous fluids manage hypovolemia but are not prioritized for trauma patient brain injuries. Replacing lost CSF requires specific medical intervention rather than fluid volume adjustments alone.

Choice D rationale

Antibiotics treat infections but are not first priority for confirmed CSF leakage, which demands careful monitoring of drainage to prevent neurological damage. Post-intervention antibiotics may be necessary.

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Correct Answer is B

Explanation

Choice A rationale

The frontal lobe controls executive functions like reasoning and planning, not object identification errors. Damage here leads to issues with decision-making and voluntary movement, not misidentification of objects.

Choice B rationale

The temporal lobe processes auditory information and object recognition. Injury disrupts the brain's ability to associate visual stimuli with correct labels, causing errors like calling a pen "a key.”.

Choice C rationale

The parietal lobe processes sensory information related to touch, pain, and spatial awareness. Damage causes difficulty with spatial relations and perception but doesn't typically involve visual misidentification.

Choice D rationale

The occipital lobe handles visual processing. Damage affects vision or visual interpretation but does not impair the recognition or labeling of objects directly.

A. Hemiparesis of the right side of the body and ataxia. B. Spasticity of the client's left arm and apraxia. C. Impulsive behavior and hostility toward family. D. Homonymous hemianopia and diplopia.

Correct Answer is A

Explanation

Choice A rationale

Hemiparesis on the right side and ataxia are common manifestations of left-sided stroke, where the motor cortex affecting the contralateral side is impaired, leading to muscle weakness and coordination loss.

Choice B rationale

Spasticity of the left arm suggests motor impairment on the ipsilateral side, which is inconsistent with the nature of left-sided strokes affecting the contralateral side. Apraxia lacks relation to motor loss here.

Choice C rationale

Impulsive behavior and hostility are more indicative of frontal lobe involvement, not motor loss secondary to left-sided strokes. These behaviors do not represent motor manifestations.

Choice D rationale

Visual defects like homonymous hemianopia and diplopia may occur in stroke but are not direct indicators of motor loss. They relate to occipital lobe or optic pathway damage.

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The nurse is caring for a trauma patient with a suspected brain injury and Battle's Sign.The nurse notices a yellow stain around fluid dripping from the patient's ear.The nurse's priority intervention will be as follows:

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is assessing a client experiencing motor loss as the result of a left-sided stroke.Which clinical manifestations would the nurse document?

Correct Answer is A

Explanation

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The nurse is caring for a trauma patient with a suspected brain injury and Battle's Sign.
The nurse notices a yellow stain around fluid dripping from the patient's ear.
The nurse's priority intervention will be as follows: