Nokea
A 24-year old woman presents to the emergency department and appears as shown in the exhibit. What type of injury does this assessment finding suggest?
- A. CSF leak
- B. Basilar skull fracture
- C. Brown-Sequard syndrome
- D. Subarachnoid hemorrhage
Correct Answer: B
Rationale: Without the exhibit, basilar skull fracture is assumed due to context (e.g., raccoon eyes or CSF leak signs).
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The nurse is caring for a client with a basilar skull fracture. Which assessment finding requires immediate follow-up?
- A. Periorbital ecchymosis
- B. Retroauricular or mastoid ecchymosis
- C. Temperature 100.9°F (38.3°C)
- D. Headache
Correct Answer: A,B
Rationale: Periorbital and retroauricular ecchymosis (raccoon eyes and Battle's sign) are hallmark signs of basilar skull fracture, requiring immediate follow-up.
The following scenario applies to the next 6 items
The nurse in the emergency department (ED) is caring for a 20-year-old female client
Item 2 of 6
ED Triage Note
History And Physical
0912: Client was brought to the ED by her two college roommates 'because she was not acting right.' The roommate reports that she went to bed the night before reporting stiffness in her neck and a headache. She attributed it to being under pressure with final exams and having poor sleep the previous several days. The client apparently took non-prescribed lorazepam from another roommate to assist her with sleep. The roommate reported recently having influenza and is unsure if she became infected. It is reported that she declined the influenza vaccination when it was offered on campus. The roommate reports waking her with physical stimuli and found her diaphoretic, hot to touch, and mumbling, saying she did not feel well.
Vital signs: T 103.4° F (39.7° C), P 112, RR 12, BP 116/86, pulse oximetry 95% on room air.
For each client finding below, click to specify if the finding is consistent with the disease process of benzodiazepine toxicity, bacterial meningitis, or influenza:
- A. Altered mental status
- B. Fever
- C. Petechial rash
- D. Altered speech pattern
- E. Neck stiffness
Correct Answer: A,B,C,B,A,B
Rationale: Altered mental status is common in benzodiazepine toxicity (sedation) and bacterial meningitis (infection-related). Fever is typical in bacterial meningitis and influenza. Petechial rash is a hallmark of bacterial meningitis, especially meningococcal. Altered speech can occur in benzodiazepine toxicity (slurred speech) and meningitis (neurological impairment). Neck stiffness is a classic sign of bacterial meningitis.
The nurse is caring for a client who has an exacerbation of Bell's palsy and is experiencing paralysis of their eye. Which of the following actions should the nurse take?
- A. Tape an eye patch to the affected eyelid at all times.
- B. Instruct the client to keep both eyes closed.
- C. Assess the pupil's size and reactivity to light.
- D. Apply the prescribed ocular lubricant to the affected eye.
Correct Answer: D
Rationale: Ocular lubricant prevents corneal damage in Bell's palsy due to impaired eye closure.
The nurse is caring for a client who has been prescribed carbidopa-levodopa for Parkinson's disease. The nurse should instruct the client that this medication may cause Select all that apply.
- A. Urine to appear darker
- B. Hallucinations
- C. Dizziness upon standing
- D. Dry, non-productive cough
- E. Painful rash that spreads and blisters
Correct Answer: A,B,C
Rationale: Carbidopa-levodopa can cause darker urine (due to metabolism), hallucinations (a CNS side effect), and dizziness upon standing (orthostatic hypotension). Dry cough and rashes are not typical side effects.
The nurse is caring for a client who has been prescribed carbidopa-levodopa for Parkinson's disease. The nurse should instruct the client that this medication may cause Select all that apply.
- A. Urine to appear darker
- B. Hallucinations
- C. Dizziness upon standing
- D. Dry, non-productive cough
- E. Painful rash that spreads and blisters
Correct Answer: A,B,C
Rationale: Carbidopa-levodopa can cause darker urine (due to metabolism), hallucinations (a CNS side effect), and dizziness upon standing (orthostatic hypotension). Dry cough and rashes are not typical side effects.