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 D

Explanation

Choice A rationale: This is a sign of worsening diabetes insipidus.

Choice B rationale: This shows signs of overhydration, as urine output is high and specific gravity is high.

Choice C rationale: This is a sign of worsening diabetes insipidus.

Choice D rationale: Vasopressin is a hormone that helps the kidneys retain water and concentrate urine. Diabetes insipidus is a condition where the body does not produce enough vasopressin or does not respond to it, resulting in excessive urination and diluted urine. The goal of vasopressin therapy is to reduce urine output and increase urine concentration, which indicates that the kidneys are functioning properly and the body is hydrated.

A. Provide thickened fluids with a straw. B. Listen to bilateral lung and bowel sounds. C. Check the client's Hypoglossal nerve and Vestibulocochlear cranial nerve function. D. Check the client's Glossopharyngeal nerve and Vagus cranial nerve function.

Correct Answer is D

Explanation

Choice A rationale: Providing thickened fluids with a straw is more related to swallowing difficulties and is not the priority in this context.

Choice B rationale: While assessing lung and bowel sounds is important, it's not directly related to offering oral intake after a gastroscopy.

Choice C rationale: Assessing the Hypoglossal nerve and Vestibulocochlear cranial nerve function isn't directly related to offering oral intake post-gastroscopy.

Choice D rationale: Checking the client's Glossopharyngeal nerve and Vagus cranial nerve function is crucial as these nerves play roles in swallowing, taste, and the gag reflex, which are important before allowing oral intake post-gastroscopy.

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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

A client has received vasopressin for diabetes insipidus. Which assessment finding indicates the most therapeutic response to this therapy?

Correct Answer is D

Explanation

A client who is fully awake after a gastroscopy asks the nurse for something to drink. After confirming that liquids are allowed, which assessment action should the nurse consider a priority before offering oral intake?

Correct Answer is D

Explanation

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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?

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