Which pieces of information link up correctly?
Nausea and vomiting: an indication of a diffuse brain stem injury.
Nuchal rigidity: neck stiffness due to meningeal edema.
Bilateral fixed and dilated pupils: an indication of a cerebellar brain attack.
Brudzinski’s sign: an indication of viral meningitis.
The Correct Answer is B
Choice A rationale
Nausea and vomiting can be caused by various conditions, including gastrointestinal issues and brain injuries, but they are not specifically indicative of a diffuse brain stem injury.
Choice B rationale
Nuchal rigidity, or neck stiffness, is a classic sign of meningeal irritation, often due to meningeal edema in conditions like meningitis.
Choice C rationale
Bilateral fixed and dilated pupils are more commonly associated with severe brain injury or increased intracranial pressure, not specifically a cerebellar brain attack.
Choice D rationale
Brudzinski’s sign is a physical exam finding indicative of meningeal irritation, commonly seen in bacterial meningitis, not specifically viral meningitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Administering diuretic medication as prescribed is an important intervention for managing fluid overload in heart failure. Diuretics help reduce fluid accumulation by increasing urine output, which can alleviate symptoms such as swelling and shortness of breath. However, before administering any medication, it is crucial to assess the client’s current respiratory status and oxygen saturation to determine the severity of their condition and ensure that the intervention is appropriate and safe.
Choice B rationale
Elevating the client’s legs can help reduce swelling in the lower extremities by promoting venous return and decreasing fluid accumulation. While this intervention can provide some relief, it does not address the immediate concern of the client’s respiratory status. Assessing the client’s respiratory status and oxygen saturation is a priority to ensure that they are receiving adequate oxygenation and to identify any potential respiratory distress that may require urgent intervention.
Choice C rationale
Assessing the client’s respiratory status and oxygen saturation is the first priority in this scenario. Heart failure can lead to pulmonary congestion and impaired gas exchange, resulting in shortness of breath and decreased oxygen levels. By assessing the client’s respiratory status and oxygen saturation, the nurse can determine the severity of the client’s condition, identify any immediate respiratory needs, and implement appropriate interventions to improve oxygenation and respiratory function.
Choice D rationale
Restricting fluid intake is a common intervention for managing fluid overload in heart failure. By limiting fluid intake, the nurse can help prevent further fluid accumulation and reduce the risk of worsening symptoms. However, this intervention does not address the immediate concern of the client’s respiratory status. Assessing the client’s respiratory status and oxygen saturation is a priority to ensure that they are receiving adequate oxygenation and to identify any potential respiratory distress that may require urgent intervention.
Correct Answer is D
Explanation
Choice A rationale
The left extrapyramidal tract is involved in motor control, but lesions here would not cause right homonymous hemianopia or inability to move the right arm. These symptoms are more indicative of a lesion in the cerebral hemisphere.
Choice B rationale
A lesion in the right cerebral hemisphere would cause left-sided symptoms, not right-sided. The patient’s symptoms are indicative of a lesion in the left cerebral hemisphere.
Choice C rationale
The cerebellum is involved in coordination and balance, not in causing right homonymous hemianopia or inability to move the right arm. These symptoms are more indicative of a lesion in the cerebral hemisphere.
Choice D rationale
A lesion in the left cerebral hemisphere can cause right homonymous hemianopia and inability to move the right arm. This is because the left hemisphere controls the right side of the body and processes visual information from the right visual field.
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