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A 30-year-old man was involved in a head-on collision and was unconscious for two minutes prior to EMS arrival. Five minutes before arriving at the hospital, the paramedic notices clear fluid draining from the patient's nose. Having seen this before, the paramedic places a drop from the patient's nose onto a piece of gauze. The nurse is looking for a clinical finding that is called the halo's sign. What type of fracture does the paramedic suspect the patient has?
- A. Depressed skull fracture
- B. Traumatic linear skull fracture
- C. Subarachnoid hemorrhage
- D. Basilar skull fracture
Correct Answer: D
Rationale: Halo sign (clear fluid with a yellow ring on gauze) suggests cerebrospinal fluid leak, commonly associated with basilar skull fracture.
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The nurse is caring for a client who was prescribed lamotrigine. The nurse understands that this medication is intended to treat
- A. Acute spinal shock
- B. Epilepsy
- C. Parkinson's disease
- D. Multiple sclerosis
Correct Answer: B
Rationale: Lamotrigine is an anticonvulsant primarily used to treat epilepsy. It is not indicated for spinal shock, Parkinson's disease, or multiple sclerosis.
The nurse has received a prescription for a mannitol infusion. Which type of intravenous tubing should be used to administer mannitol?
- A. Microdrip
- B. Filtered
- C. Vented
- D. Non-vented
Correct Answer: B
Rationale: Mannitol is a hyperosmolar diuretic that can crystallize in IV tubing, potentially causing blockages. Filtered tubing is required to prevent crystals from entering the bloodstream, ensuring safe administration. Microdrip, vented, and non-vented tubing do not address this risk.
The nurse gives discharge instructions to a client who sustained a brain injury from a motor vehicle accident. His wife is concerned regarding her husband having seizures at home. Which statement from the wife indicates that she understood the nurse's teaching?
- A. I will make sure that my husband does not wet himself.'
- B. I will clear all furniture that might injure him when he has a seizure.'
- C. I will call 911 once he has a seizure lasting about 3 minutes.'
- D. I will ensure he sleeps well after a seizure.'
Correct Answer: B
Rationale: Clearing furniture prevents injury during seizures, indicating understanding of safety measures.
The nurse is observing a client with epilepsy have a sudden loss of muscle tone that lasts for a few seconds. The nurse is correct in identifying this as which of the following?
- A. Atonic seizure
- B. Tonic-clonic seizure
- C. Absence seizure
- D. Complex partial seizure
Correct Answer: A
Rationale: Atonic seizures involve a sudden loss of muscle tone, often causing falls.
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 4 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 potential nursing intervention, click to specify whether the intervention is indicated or not indicated for the care of the client: A= Indicated, B= Not Indicated
- A. Keep the door to the client's room closed to maintain negative airflow
- B. Provide visitors with face shields upon entering the client's room
- C. Provide a quiet environment
- D. Perform frequent neurological assessments
- E. Obtain an order to start a peripheral vascular access device
- F. Prepare the client for an immediate electroencephalography (EEG)
Correct Answer: B,B,A,A,A,B
Rationale: Negative airflow is not typically required for bacterial meningitis unless airborne precautions are specified. Face shields are not standard for meningitis; droplet precautions are usually sufficient. A quiet environment reduces stimulation for a client with neurological symptoms. Frequent neurological assessments are critical for monitoring meningitis progression. IV access is necessary for administering antibiotics and fluids in suspected meningitis. EEG is not indicated unless seizures are suspected.