The nurse is teaching a class to a group of staff nurses about traumatic brain injury which condition would the nurse identify as having the highest risk of a fatal outcome within the first 24 hours post-injury?

Subdural hematoma

Diffuse axonal injury

Intracranial hemorrhage

Epidural hematoma

Answer and Explanation

The Correct Answer is D

A. Subdural hematoma: Subdural hematomas develop more slowly and typically present a higher risk for delayed deterioration, but not usually within the first 24 hours.

B. Diffuse axonal injury: While severe, diffuse axonal injury typically causes a prolonged coma rather than immediate fatality within 24 hours.

C. Intracranial hemorrhage: This is severe but often depends on the size and location of the bleed.

D. Epidural hematoma: Epidural hematomas are associated with arterial bleeding and rapid deterioration due to increased intracranial pressure, making them the most fatal within 24 hours.

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Correct Answer is D

Explanation

A. Restlessness: This may occur in the pre-active phase of dying but is not specific to the actively dying phase.

B. Decreased appetite: A reduced appetite is common earlier in the dying process, not specific to the actively dying phase.

C. Skin pallor: Skin changes, such as pallor, occur earlier; mottling is more indicative of the actively dying phase.

D. Anuria: Anuria (absence of urine output) is a hallmark sign of multisystem failure and the actively dying phase.

A. Atrial tachycardia B. Ventricular fibrillation C. Atrial flutter D. Sinus bradycardia

Correct Answer is C

Explanation

A. Atrial tachycardia: Atrial tachycardia is a rapid heart rhythm originating from the atria, but it does not have the characteristic "sawtooth" pattern seen in atrial flutter.

B. Ventricular fibrillation: Ventricular fibrillation is a chaotic rhythm originating from the ventricles, characterized by irregular, rapid waves with no discernible P waves or QRS complexes.

C. Atrial flutter: Atrial flutter is recognized by a "sawtooth" pattern of P waves, indicating rapid atrial depolarizations.

D. Sinus bradycardia: Sinus bradycardia is a slow but regular rhythm originating from the sinus node, with normal P waves and QRS complexes.

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The nurse is teaching a class to a group of staff nurses about traumatic brain injury which condition would the nurse identify as having the highest risk of a fatal outcome within the first 24 hours post-injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who is near death. Which of the following findings would indicate to the nurse that the client is in the actively dying phase?

Correct Answer is D

Explanation

The nurse is documenting a client’s assessment. The rhythm below was obtained from the client’s cardiac monitor. How should the nurse document this strip?

Correct Answer is C

Explanation

A client has been admitted with a head injury from a motor vehicle accident. Vital signs on admission were BP 120/80 mm Hg and pulse 88. Which vital signs would indicate that Cushing's triad was occurring?

The nurse is monitoring a 53-year-old client who is undergoing a cardiac exercise stress test after experiencing an episode of angina. Which client finding will require the test to be discontinued?

The nurse is teaching a class to a group of staff nurses about traumatic brain injury which condition would the nurse identify as having the highest risk of a fatal outcome within the first 24 hours post-injury?

After exercising, a client is hooked up to a cardiac monitor. The rhythm below is noted. How should the nurse document this rhythm?

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The nurse is assessing a brain-injured client response to nail bed pressure. The client demonstrates internal rotation, adduction, and flexion of the arms, the nurse should report the response as which finding

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