While reviewing the clinical history of a client with brain injury, the nurse finds that there is a periorbital ecchymosis, which is referred to as raccoon eyes. The client also has leakage of cerebrospinal fluid (CSF) from the nose. Which fracture should the nurse suspect in the client?

Depressed fracture

Basilar skull fracture

Linear fracture

Frontal fossa fracture

Answer and Explanation

The Correct Answer is B

Choice A rationale: Often results from direct trauma to the skull, but not typically associated with CSF leakage or raccoon eyes.

Choice B rationale: Basilar skull fractures, particularly involving the anterior or middle fossa, can lead to CSF leakage from the nose (rhinorrhea) and periorbital ecchymosis (raccoon eyes).

Choice C rationale: A simple fracture line without displacement, less likely to cause CSF leakage and raccoon eyes.

Choice D rationale: Less commonly associated with CSF leakage and periorbital ecchymosis compared to basilar skull fractures.

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Correct Answer is C

Explanation

Choice A rationale: This is a general description of an imaging test, such as an X-ray, ultrasound, or MRI, which can show the structure of the organs but not the mucosal lining.

Choice B rationale: This is a general description of a blood test, which can show signs of infection, inflammation, or anemia, but not the cause of these problems.

Choice C rationale: This exam is called a colonoscopy, which involves inserting a flexible tube with a camera and light into the anus and advancing it through the colon. A colonoscopy can reveal signs of inflammation, ulcers, bleeding, or narrowing of the intestinal wall that are characteristic of Crohn's disease. A biopsy can also be taken during the procedure to confirm the diagnosis.

Choice D rationale: This is a general description of a urine test, which can show signs of kidney problems, urinary tract infections, or dehydration, but not Crohn's disease.

A. Impaired physical mobility related to decreased motor agility secondary to ALS as manifested by inability to ambulate. B. Hopelessness related to impaired ability to cope. C. Caregiver role strain related to care recipient's unrealistic expectations of caregiver. D. Impaired memory related to reduced quality and quantity of information processed.

Correct Answer is A

Explanation

Choice A rationale: In ALS, impaired physical mobility due to decreased motor agility and the inability to ambulate is a direct consequence of the disease.

Choice B rationale: Hopelessness might be a possible emotional response but doesn't address the client's physical limitations due to ALS.

Choice C rationale: Caregiver role strain is related to the family's ability to manage caregiving responsibilities and is not the primary concern for the client's physical mobility.

Choice D rationale: Impaired memory is not the primary issue in ALS; the client's inability to ambulate due to decreased motor function is the main focus for this nursing diagnosis.

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While reviewing the clinical history of a client with brain injury, the nurse finds that there is a periorbital ecchymosis, which is referred to as raccoon eyes. The client also has leakage of cerebrospinal fluid (CSF) from the nose. Which fracture should the nurse suspect in the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Upon physical examination, the nurse detects abdominal tenderness, increased bowel sounds accompanied by signs of borborygmi, abdominal distension, and tympany on percussion. Which diagnostic test will confirm Crohn's disease in the client?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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